Test | When Words Count Retreat

A. Fill out and submit this form by our extended deadline of: 11:59 PM, EST, Friday, January 3rd , 2014, as the first step in claiming your prize. Late submissions will be disqualified and alternate winners will be selected.

First Name *

Last Name *

Street Address *

City *

State/Province *

Zip *

Country *

Primary Email *

Home/Cell Phone *

I have published, or am currently writing, a book. *

I have published, or am currently writing, a book.

I attest to the truthfulness and accuracy of the personal information provided above and hereby incorporate it into the Affidavit of Eligibility and Standard Release forms below. *

I attest to the truthfulness and accuracy of the personal information provided above and hereby incorporate it into the Affidavit of Eligibility and Standard Release forms below.

B. Please read carefully and then approve each of the following documents:

I agree to terms and conditions of Affidavit of Eligibility (read) *

I agree to terms and conditions of Affidavit of Eligibility (read)

I agree to terms and conditions of Standard Release Form (read) Affidavit of Eligibility (read) *

I agree to terms and conditions of Standard Release Form (read)

Also, for your convenience, you may download the forms, print, complete, sign and return them by mail (hard copy) or email (scan).

Email: sales@whenwordscountretreat.com

Mail: Sales c/o When Words Count Retreat

1764 Marsh Brook Road

Rochester, VT 05767

C. Reserve Your Stay:

Use the form below to reserve your visit dates and to calculate your required Room Hold Deposit.Reserve a Date in the First Half of January, 2014 and Get an Extra Night!!! (Based on availability).

Select Arrival Month *

Select Days *

Select Dates *

You are eligible for a FREE night with your stay (not including meals), because you booked your arrival for a start date prior to January 15, 2013!

You are eligible to add an extra FREE night to your stay (not including meals), because you booked your arrival for a start date prior to January 15, 2014!

Number in your party *