Application Form

Name *

Name

First Name

Last Name

Email Address *

Address *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Phone

(###)

###

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Retreat Week *

Week One - Poetry

Week Two - Breaking into Your Story

Dietary Issues or Concerns

Mobility Issues or Concerns

Require Transport from Airport?

Yes

Early Arrival?

Monday

Tuesday

Both

Please share something about yourself as a writer. *

How long have you been writing and in which genres do you mainly work? Have you been published? If so, please list the periodicals or publisher and title(s) of your work. If you are unpublished, please email a sample of your writing (at least 3-4 poems or 4-5 pages of prose) to director@mosswoodretreats.com .