Ecospirituality Application Form

Diocese of Willochra
PO Box 96,
Gladstone SA 5473

Fax: (08) 8662 2027
Phone: (08) 8662 2249
Email: reception@diowillochra.org.au

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 (3% surcharge applies)
Card Number:
Expiry Date:	CVC: (3 digits on back of card)
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?

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 Eco-Spirituality programs is $630 but $730 for Angepena

Please make cheques payable to: THE DIOCESE OF WILLOCHRA
Visa, Mastercard or Bankcard facilities are available. 3% surcharge applies for credit card transactions
Payment by monthly installments or other agreed to arrangements is quite acceptable. COST INCLUDES: Accommodation, meals, facilitation and transport to areas where non-conventional vehicles are required.

For more information, please use space below:

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Your Details