Women's Acts Retreat Registration Form

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Home phone REQUIRED Please fill out this field. Please enter a phone number.

Preferred Name (for name tag) REQUIRED Please fill out this field. Please enter valid data.

Address REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Work Phone REQUIRED Please fill out this field. Please enter a phone number.

Cell Phone REQUIRED Please fill out this field. Please enter a phone number.

I agree to allow my contact information to be published in the Women's ACTS retreat directory. REQUIRED Yes No Please fill out this field.

I agree to allow my picture to be published in the Women's ACTS retreat directory. REQUIRED Yes No Please fill out this field.

Age (must be over 21) REQUIRED Please fill out this field. Please enter an integer (number).

Email REQUIRED Please fill out this field. Please enter an email address.

Occupation Please enter valid data.

Marital Status REQUIRED Married Single Widowed Separated Please fill out this field.

Parish or church you attend Please enter valid data.

City of parish or church you attend Please enter valid data.

If not Catholic, what affiliation? Please enter valid data.

Did someone tell you about this retreat? If so, who? Please enter valid data.

Do you have any specific needs? Check any that apply: Dietary Medical Physical Financial Assistance

Please tell us about your specific needs

Emergency Contact Information

Spouse or Emergency Contact Name REQUIRED Please fill out this field. Please enter valid data.

Spouse or Emergency Contact Phone Number REQUIRED Please fill out this field. Please enter valid data.

Spouse or Emergency Contact Email REQUIRED Please fill out this field. Please enter valid data.

Someone to pray for you

Name of someone to pray for you during the retreat REQUIRED Please fill out this field. Please enter valid data.
Phone Number of someone to pray for you during the retreat REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Email of someone to pray for you during the retreat REQUIRED Please fill out this field. Please enter an email address.
Relationship of someone to pray for you during the retreat REQUIRED Please fill out this field. Please enter valid data.
Refund Policy: Full refund on or before 9/9/24, Half Refund 9/10/24 - 9/22/24, No Refund on or after 9/23/24. I agree to the ACTS Retreat Refund Policy REQUIRED Yes No Please fill out this field.
Retreat Fee225.0