Primary Phone:   Alternate Phone:

Mailing address:

Email address:   Marital Status: Choose one Single Married Divorced Widowed

If married, spouse name:  

Spouse phone number:

If married, has your spouse attended or submitted an application to attend? Yes No

How many children do you have?  

Name to be used on your nametag:

Your occupation:     Date of Birth:

Highest education level: Choose one High school/GED Some college 4-year degree Masters/Doctorate Other   You are: Male Female

Denomination:   Name of Church:

Church mailing address:

Pastor/Priest/Minister's name:

Weekend you wish to attend: Men's Women's Co-ed   Date:

Sponsor's Name:   

Sponsor's phone:
Your sponsor must submit a "sponsor" application.

Medical questions:

Yes No   Do you have any special dietary requirements?  If Yes, Choose one Diabetic Vegetarian Low Salt Other

Yes No   Do you require medications at specific times each day?

Yes No   Do you have any health or physical restrictions which require special equipment, accomodations or facilities?  If yes, please explain:

The cost for the weekend is $70 per person.  This fee includes a $20 non-refundable application fee due at the time your application is submitted.  All expenses are included in the weekend price: transportation to and from the retreat site, nine meals and snacks, supplies, and three nights' accomodations.