2023 Womens Retreant Registration

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

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

Preferred Name 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.

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

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

Over 21 years old? REQUIRED Yes No Please fill out this field.

Ever attended an ACTS Retreat? REQUIRED Yes No Please fill out this field.

Are you a member of St. Edith Stein Catholic Church? REQUIRED Yes No Please fill out this field.

If not, what Parish/Church do you attend? Please enter valid data.

If someone invited you, who? Please enter valid data.

Please check any specific needs? REQUIRED N/A Dietary Medical Physical Financial Assistance Please fill out this field.

Please explain: Please enter valid data.

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

EMERGENCY CONTACT INFORMATION

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

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

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

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

To guarantee your reservation, please remit payment for the retreat deposit fee amount of $75.00 to ST. EDITH STEIN CATHOLIC CHURCH. Full payment of $275.00 is due by May 21, 2023. Please note that priority is given to parishioners of ST. EDITH STEIN CATHOLIC CHURCH.

If you have questions about the ACTS Retreat or Registration please contact, Cindy Rangel, at rangelkofc@aol.com.