ACTS Retreat Registration Form

Retiro de ACTS para Mujeres en español

Noviembre 8-11, 2018

Retreat Fee: $150.00

$0

Total
Name Name * First Last
Date of Birth Date of Birth * / MM / DD YYYY
Register Parishioner *

Register Parishioner Yes No
Envelope Number
Email *
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone (Mobile) Phone (Mobile) * - ### - ### ####
Phone (Home or Other) Phone (Home or Other) - ### - ### ####
Emergency Contact (Name) Emergency Contact (Name) * First Last
Relationship *
Emergency Contact Address Emergency Contact Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Emergency Contact Phone Emergency Contact Phone * - ### - ### ####
Allergies
List any special dietary or medical needs
Retreat Cost $150.00: Select amount to pay *

Retreat Cost $150.00: Select amount to pay $50.00 Deposit $150.00 Paid in Full
A $50.00 Non-refundable deposit is required with this registration form. In case of cancellation, the deposit WILL NOT be refunded. *

A $50.00 Non-refundable deposit is required with this registration form. In case of cancellation, the deposit WILL NOT be refunded. Agree