Family Mini-Retreat Registration
Parent Name
*
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Name of second parent (if attending)
First Name
Last Name
Please list children's names and ages. Create a new line for each child. Example: Martha, 8
Which date would you like to register for?
*
Please Select
Saturday, January 7th (all ages)
What do you hope to gain from this offering?
*
Any questions or concerns we should know about?
Sliding Scale Payment - choose the level that works for you!
prev
next
( X )
Community Supported
$
40.00
Number of people (kids included)
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
Standard
$
50.00
Number of people (kids included)
1
2
3
4
5
6
7
8
9
10
Pay It Forward
Help support other families!
$
60.00
Number of people (kids included)
1
2
3
4
5
6
7
8
9
10
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Submit
Should be Empty: