Fatherheart A School

Fatherheart A School Registration Form
Please complete one application form for each individual applicant, even if you are attending as a married couple . A non refundable deposit of 20% per applicant ($80.00) is required with your application form. Cheques should be made payable to: Grace Church in the memo write: A School. The balance will be required 4 weeks before the event (March 18) or you can pay in full on application

Please mail checks to: Julie Rolland, 6392 Tintern Cir. W., Jacksonville, Fl. 32244
Name

First NameLast Name
E-mail
Phone Number

Area CodePhone Number
Date of Birth

MonthDayYear
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Please answer the following questions as openly and honestly as you can. All answers will be treated in the strictest confidence.
What is your reason/motivation for wanting to attend?
What changes/breakthroughs do you hope to see in your life after attending?
How did you hear about this event?
Medical Health
Do you have any special needs/requirements, or special dietary requirements which we need to be aware of in order to facilitate your attendance? If not indicated we will assume no.
Do you suffer from any health conditions or illnesses which it would be helpful for us to be aware of (eg heart trouble, diabetes, epilepsy, asthma, allergies etc)? If so, are you on any special medication related to those conditions?
Emergency Contact

In case of any problems during your stay, we would appreciate the address and telephone number of an emergency contact and their relationship to you.
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Relationship to You
Payment Information
Payment Method
Payment (if paying by Credit Card)
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Full Registration$399.00

Deposit Only$80.00

Balance Due (after deposit)$319.00

Alumni Rate$250.00
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Fatherheart A School Registration Form

Please answer the following questions as openly and honestly as you can. All answers will be treated in the strictest confidence.

Medical Health

Emergency Contact

Payment Information

Payment (if paying by Credit Card)