May 29-31 Prescription for Love Registration

Prescription for Love

May 29-31, 2026

Contact Information

(Please Register Each Person Separately)

Preferred First Name & Last Name

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country *

Occupation *

Birthdate: Day / Month / Year *

Primary or Mobile Phone *

Home or Secondary Phone

Email Address *

Emergency Contact Name *

Emergency Contact Phone Number *

List All Known Allergies and Medical Conditions *

Do you have mobility issues? *NoYes

Room Options

Bed PreferencesSeparate BedsShared Bed

Name of Roommate

Deposit

A $300 deposit is required to complete your registration. Your registration will not be confirmed until we receive your deposit.

I Choose To Pay The Deposit ViaCredit Card: (After submitting registration, phone Jana: 587-877-0347)Cheque: (by Mail) 29 Squaw Valley Road, Lumby, BC V0E 2G6

Comments & Questions

Prescription for Love

Contact Information

Room Options

Deposit

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