Individual Retreat - Credit Card Payment

Individual Retreat - Credit Card Payment
Contact and Emergency Contact Information
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Start Date of Your Retreat*

MonthDayYear
Date
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Automobile*

I will be bringing a carI will not have a car
Description of the Automobile that you will Park on our Lot
Make:*
Model:*
Color:*
License Plate Number*
State of License Plate*
Retreat Type and Payment Information
Is this a directed retreat?*

YesNo
Directed Retreat (Accommodations/Meals/Spiritual Direction)
Insert amount due here.
Private Retreat (Accommodations/Meals)
Insert amount due here.
"FUND A NEED" - Would you like to add a donation to help someone who currently cannot afford the full cost of a retreat?

YesNo
Donation amount
Insert amount here
Subtotal of Individual Retreat Payments

Total (in U.S. Dollars)*

USDIndividual Retreat Payment Totaled for You

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

Refund Information

With 24 hour advanced notice, a full or partial refund can be issued if you must cancel or change your retreat plans. No refund will be issued if you fail to notify us or to arrive for your retreat.
Should be Empty: