WIN! CLAIMS FORM | When Words Count Retreat

#1. Fill out and submit this form and then

#2 Pay your Meal Deposit/Room Hold as indicated on the separate PayPal page. (Late submissions will be disqualified and alternate winners will be selected.)

First Name*

Last Name*

Primary Email*

Home/Cell Phone*

I am a published author currently writing on a new book.*

I am a citizen of the United States or Canada, who is at least 18 years of age and am currently writing a new 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.

Choose/Confirm your May Dates below.

First Choice

Month*

Days *

Second Choice:

Month*

Days *

Alternate Date in April:

Month*

Days *

Choose the number in your party and determine your Meal Deposit/Room Hold Cost

Number in your party*

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