Recovery Connection
Treatment Program
Linda C. Paoli LCSW, CSAT-S, Director
3433 American River Drive, Ste. A
Sacramento, CA 95864
916-972-7831
Registration
Intensive Treatment Marathon
October 21 & 22, 2011
Name_____________________________________________
Telephone#_________________
Address__________________________________________________
City_______________________State_________Zip Code:_________
Email (Please print clearly) _________________________________
Deposit of $250. required with registration through May 24, 2011. Balance of $400. required after September 21, 2011.
Full payment of $650.00 required with registration
September 21, 2011 or later.
Complete this form and mail it with your non-refundable deposit made payable to:
Charlene Conley LCSW
1212 High Street
Auburn, CA 95603
I have read and understand that my deposit
is nonrefundable.
______________________________________________
Signature
I understand that total payment of $650. is non-
refundable after September 21, 2011.
______________________________________________
Signature
Sign up for my newsletter: Recover & Connect!
Individuals of all cultural backgrounds/ sexual orientations welcome.
All major credit and debit cards accepted.
"A ship in the harbor is safe, but that is not what ships are made for”
I am interested in a massage at $75.00 Yes _____ No _____
I am interested in sharing a room Yes_____ No _____
I am interested in carpooling Yes ____ No ______
I am vegetarian Yes _____ No______
I authorize Linda Paoli and Charlene Conley to release my name and telephone number to other marathon participants, for purposes of carpooling and/or room sharing.
_______________________________________________________________ __________________________
Signature Date_______________________________________________
I authorize Linda Paoli and Charlene Conley to share confidential information about me with each other and any clinical assistants that will be counseling me during the treatment period.
__________________________________________________ Signature Date ______________________________________________