testing form | The Interhelp Network

Name *

First

Last

E-mail *

Phone number *

Address *

Names and ages of children attending (contact us to make sure there is still space)

Accommodation – check all that apply *

Additional accommodation request (e.g., roommate)

I have special dietary needs (describe)

Program Cost per person *

Scholarship Donation amount (tax deductible)

Scholarship Request amount

If requesting a scholarship, please answer scholarship application question (see Gathering Description page)

Grand Total (program cost plus scholarship donation/minus scholarship request) *

Amount enclosed (a nonrefundable $50 deposit will hold your space) *

Balance owed upon arrival *

Payment *

I am mailing a check to Interhelp, Kristina Orchard, 10A Powdermill Circle, Maynard, MA 01754
I am paying by Paypal (see below).