Name *
Please include Apartment/Suite Number and other Location data
Phone (Home) *
Phone (Home)
Phone (Office)
Phone (Office)
Phone (Mobile) *
Phone (Mobile)
Event Participation Confirmation *
I confirm my Participation in the Rome International Sircle 2017
Please choose one of the options
Please specify the number of attendees in your Group
Please write down the names of the attendees in your Group
Shared Room *
I understand that I will share a Room with someone else in the Retreat
Please write down the Name of the person with whom you are sharing a room
Private Room
I prefer to have a Private Room and I understand that there will be an extra charge of USD 1,100 (Private Rooms are very limited)
Please notify the Organizers of any Dietary Requirements and/or Restrictions
Please describe any health issues that might require special attention, such as having a medical doctor on-call, equipment or access to a pharmacy
Departure Date *
Please indicate your estimated Departure Date
Transportation *
Please indicate your mode of Transportation and if you require Reservations
Please enter the Names, E-mails and Phones of your Key Emergency Contacts
Please add a Message to the Organizers