Welcome to the Diocese of Willochra

Eco-Spiritualitv Program – Application Form

After completing form, please print and Fax or send it to us with a $25.00 deposit.

The Ven. Michael Hillier

Archdeacon Spiritual Development

Diocese of Willochra

P.O. Box 96

Gladstone 5473

Your details
Title:
Given Name
Surname
Address:

City:
State or Territory:
Postal / Zip Code:
Country:
Telephone:
Facsimile:
E-mail (required for quick response)
Credit Card Details:	Visa Mastercard Bank Card
Card Number:
Expiry Date:
Name of cardholder:
Payment Amount

# Please make cheques payable to:

THE DIOCESE OF WILLOCHRA

Visa, Mastercard or Bankcard facilities are available.

Program choice: (people will be allocated their second choice only if their first choice does not attract the minimum number of people required to run the program)


1
Date:
2
Date:
.

Contact in case of emergency:
Name:
Relationship:
Address:

Telephone:	(Home)
	(Business)
.
Any special dietary requirements?
m
Have you previously been involved in this program? Yes No
Are you willing to "car share" with other people? Yes No
Please note that the cost for all Eco-Spirituality programs is $545.00, except Angepena $635.00.
Please make cheques available to:
THE DIOCESE OF WILLOCHRA
Visa, Mastercard or Bankcard facilities are available.
Payment by monthly instalments or other agreed to arrangements is quite acceptable.
COST INCLUDES: Accommodation, meals, facilitation and transport to areas where non-conventional vehicles are required.
Michael can also be contacted as follows:
Phone: (08) 8892 2313
Email: stmaryburra@bigpond.com
or
Terry
Phone: (08) 8682 1571
Email patez1@yahoo.com

For more information, please use space below:

After completing form, please print and Fax or send it to us.