International Holistic Centers Gathering
Breitenbush Hot Springs
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Center Affiliation (if applicable)
Reservations
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Grove Room
Queen Bed - Single occupancy
$
1,185.00
Attendees
Grove Room
Queen Bed - Double occupancy
$
810.00
Attendees
Yurt
Double Occupancy
$
400.00
Attendees
Femme Dorm
Yurt shared with 5 others
$
300.00
Attendees
Online Attendee
Provide description here.
$
100.00
Quantity
Support Bursary Fund
$
50.00
Donation
0
1
2
3
4
5
6
7
8
9
10
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
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