Registration Form
Please complete and submit this form to register for the Women's Emmaus Retreat.
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parish
Please Select
St. Anthony
St. Joseph - Lakeland
St. Joseph - Winter Haven
Resurrection
Email
example@example.com
Phone Number
Please enter a valid phone number.
Shirt Size
Please Select
Small (S)
Medium (M)
Large (L)
Extra Large (XL)
Double Extra Large (XXL)
Triple Extra Large (XXL)
Age
Retreat Cost
The cost of the retreat is $150 for a shared room. A single room costs $170. Please let us know if you need a scholarship to attend the retreat.
I need a scholarship:
Yes
No
I would like to have a single room (cost=$170):
Yes
No
Payment
Payment for the retreat is handled separately. Please send payment to: Laura Summers at 1221 Stratton Drive, Lakeland, FL 33813. MAKE CHECKS PAYABLE TO RESURRECTION CATHOLIC CHURCH. In the memo line, write: Women's English Emmaus.
Emergency Contact
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Dietary Restrictions
Please note any dietary restrictions (if applicable)
Submit
Should be Empty: