Name

First Name

Last Name

Phone

(###)

###

####

ADDRESS

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date Of Birth *

MM

DD

YYYY

Will you be requiring a private room? *

A guaranteed private room with a private bathroom is an additional fee of $500 due at time of registration.

YES

NO

Name of Emergency Contact * *

First Name

Last Name

Emergency Contact Phone Number *

Country

(###)

###

####

I have read and understand the polices for Lotta's Åland Retreat. *

Policies can be found at www.jansdotter.com/policies

YES