Team Member Registation

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 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 Please enter a phone number.

Cell Phone Please enter a phone number.

Age Please enter an integer (number).

Include my contact information and picture in the ACTS directory REQUIRED Yes No Please fill out this field.

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?

(i.e. prescription meds, trouble walking on the retreat grounds, etc.)

Dietary Medical Physical

Specific Needs Details

Emergency Contact

Spouse or Emergency Contact Name REQUIRED Please fill out this field. Please enter valid data.
Spouse or Emergency Contact Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Spouse or Emergency Contact Email REQUIRED Please fill out this field. Please enter an email address.

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.

Team Member Retreat Fee150.0