Program Registration - Credit Card Purchase

Mercy Center Program Registration
Fill out this retreat registration form for each person who will be attending. You will be able to pay for your event through a secure online payment processor (Authorize.net). Please go to mercycenterstl.org to the Program Section for our cancellation policy.

You may initiate the registration process for any of our programs by completing this form. Please note that registration for all of our programs is complete upon receipt of payment.
Program Registration - Mindful Meet-Up - December 15*
Subtotal of Registration Fee

Program Registration Total*

USD

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Person Paying*

SelfOther
If Other, Please Enter Name of Person Paying
If your program registration includes overnight accommodations, please note any special requirements below (including, if Double Occupancy, with whom you will share a room).
Overnight or Commuter

CommuterOvernight
If Double Occupancy, enter Name of Person with whom you will share a room. Note: each person must pay separately.
Special Dietary Needs

Gluten freeDairy freeVegetarianVegan
If you have other dietary needs, please list them below. We cannot guarantee that we will be able to accommodate them at all the meals, however.
How Did You Find Out About This Program?*

Parish bulletinElectronic communicationMercy Center mailed scheduleMercy Center websiteA friendOther
If parish bulletin - what parish?
If other, how else did you find out about this program?
Should be Empty:

Mercy Center Program Registration