* 1. For which retreat(s) are you registering?

* 2. Name

* 3. Primary Language Spoken

* 4. Email Address

* 5. Phone

* 6. Partner's Name

* 7. Primary Language Spoken

* 8. Email Address

* 9. Phone

* 10. Sandwich options (choose one for your partner and one for yourself)

* 11. Please list any food allergies and/or dietary preferences for you and your partner:

Person to Notify in Case of Emergency

* 12. Name

* 13. Primary Language Spoken

* 14. Phone

* 15. Email Address

* 16. License Plate State/Number (if parking authorization needed)

Please send or drop off $20 registration fee to UCI CARE, G320 Student Center no later than Wednesday, October 19, 2016.

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