HEALING WEEKEND Application Form

*** Please do not make airline reservations until we confirm your weekend.

If you are paying by Credit Card, the address you give must be the address at which you receive your Credit Card Bill.

*  = Required

  Salutation   Mr.    Mrs.     Ms  *   First:   * Last:
*  Street 1 :     Street 2: 
* City:     * State/Prov.:    Zip:     * Country:  
*  Home Tel.: Bus. Tel.:
* E-mail: * Confirm  E-mail:  
  I am an     Adoptee      First Mom               I wish to borrow a sleeping bag   
 *   By placing an 'X' in the box to the left, I agree to wait until my weekend is confirmed to make my travel arrangements and I assume all responsibility for my travel costs.
*   By placing an 'X' in the box to the left, I  agree to the following 2 items:  1.)  I understand and agree that the fees for these weekends are non-refundable.  2.)   If a replacement for my spot is found, a $75 cancellation fee will be charged and the remainder of the  fee that I paid  will be applied to a future weekend.. else the fee is forfeited.

We suggest you take out travel insurance to protect yourself in case you are unable to attend.

* Food Requirements:      Check if you have a car 

                     Payment Information                                             credit cards

*Healing Weekend $250 USD (Non-Refundable)                                      $150 deposit required
  Mother/DaughterWeekend $300 USD (Non-Refundable)                     $150 deposit required
  Healing/Vacation Week in Caribbean $999 USD (Non-Refundable)   $500 deposit required

 ** Balance is due four weeks prior to your weekend

* Total Amount of payment:    * Date of Weekend: 

Payment By: Name on Card: 

Card No. Card Expires

Security Code What is the security code?
If you are Not paying by credit card, enter 00 in the Security Code Box above.

Signature _______________________________________        Date ________________

You may make your payment by faxing your Name and Credit Card info to: 845-267-2736, or you may Call 845-268-0283 and leave the info on our answering machine, or you may send the payment via US Mail to:

Adoption Crossroads
74 Lakewood Drive
Congers, NY 10920-1710

If paying by check, make the check out to Adoption Crossroads.

You must, no matter how you pay, send this form with your signature and date of signing to us at the address below

 Please press the SUBMIT button below

If you do not receive an acknowledgement of your registration within 48 hours,
 please email me to verify that I received it.


To get more information or to sign up by phone: call 845-268-0283
or send E-mail to us at joesoll@adoptioncrossroads.org.mailbox

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Last Updated on November 1, 2003 by Joe Soll

© Copyright 2003 Adoption Crossroads all rights reserved; logo's and graphics appearing on these pages are trademarks of Adoption Crossroads and may not be used or reproduced without permission.  CERA is a New York State d.b.a. of Adoption Crossroads.