CHATEAU DUMAS REGISTRATION FORM

Name

First Name

Last Name

Personal mobile/cell phone number

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Dietary Requirements

please let us know if you have any dietary allergies or requirements, eg, vegetarian. If you are coming with someone who is not participating in the workshop, please list their dietary requirements here too

Medical Conditions or Special Requests

please let us know if you have any medical conditions you think we should know about or any special requests. If you are coming with someone who is not participating in the workshop, please let us have details of any medical condition we should know about

Emergency Contact Name

Emergency Contact Number/Email

Please let us know where you heard about us

We will ask you to provide us with your incoming and outgoing travel information three months before the start of your workshop at Chateau Dumas