nurturing the relationship between spirituality and social justice

Leaven's Home Page

You can reach us by e-mail at leavencenter@leaven.org

by mail at
Leaven
P.O. Box 97
Lyons, MI 48851

or by phone at
989/855-2606 or
989/855-2277.

Leaven home page

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Print out and mail this form

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Register at least one month prior to the event, if possible. Please print clearly.

Program title:_________________________ 

 

Date of program _____________

 

Name: ________________________________________________

 

Address:_______________________________________________

 

City: ______________________  State: _____   Zip: _____________

 

Telephone: (home)_________________ (work)__________________

(e-mail) _____________________

Gender ___________     

Roommate request: _______________________________

Is this your first time at the Leaven Center? _____

Are you on the Leaven mailing list? _____

Amount of deposit enclosed: $________________

(Deposit will be refunded only if you notify us at least 14 days in advance of the event.  For Canadian checks please indicate "U.S. FUNDS" next to dollar and word amount)

Will you need a barrier free room? _____

Do you need alternate formats? ____ If yes, what type(s)? __________________________

_______________________________________________________________________

Do you have any dietary restrictions? ____ If yes, what type(s)? ______________________

_______________________________________________________________________

In case of emergency contact: _______________________________________________

Tax-deductible gift enclosed for scholarship fund: $______________

____ Please send airport pick-up form

Checks should be made to "Leaven" and mailed with this form to:

Leaven
P.O. Box 97
Lyons, MI 48851