2023 Northwest Christian Singles Retreat

1
REGISTRATION INFORMATION

Welcome! We are looking forward to a FUN and FAITH-FILLED retreat. Register early to get the early bird discount.

Complete the following entries, select preferred lodging and additional optional fees. Pay by credit card online or by mail with check or money order. If you have any questions regarding this registration form, please contact Susie at 208-667-8692
2
Name* This field is required.(As you would like it to appear on your Name Tag)
First Name
Last Name
3
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
United States
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
E-mail* This field is required.We will be sending you confirmation emails & also detailed reminder emails just before the retreat. We will never sell your email address to anyone and we do hope you will check your spam/junk folder if you don't receive our confirmation email upon registration.
5
PHONE NUMBERBest number to reach you at!
Area Code
Phone Number
6
May we text you at this number?
YesNo
7
Gender* This field is required.
Male
Female
8
Your Age Range* This field is required.For statistical purposes and roommate selection
Under 20
20-29
30-39
40-49
50-59
60-69
70+
9
Home Church including City(optional)
10
Retreat FEES

The standard retreat registration fee of $175 (USD) includes 8 meals and 3 nights lodging in Midway or Teakettle Lodge and all associated speaker and retreat fees. Early bird pricing drops the standard registration fee down to $160 or even $150. Increased fees from the camp have again forced us to increase our early bird pricing 😬. The standard lodging includes only three people per room so that no one has to climb up to the top bunk. Bathrooms are down the hall.

We have room upgrades available within Midway or Teakettle Lodge. You can share your room with one other person (for an additional $50 per person) or stay in a room by yourself (for an additional $135.)

You can also upgrade to a room in Glacier Mountain Lodge with its beautiful rustic log cabin look. Each room has two queen beds and a private bath. Bedding can be provided for an additional $12/bed. Up to four people can stay in each room, but one of the four must reserve the room for all three nights (for an additional $210.) Space is limited and will be on a first-come, first-serve basis. Room is not reserved until paid in full.
11
Retreat LODGING
Standard Shared Room in Teakettle or Midway Lodges (3 people/room)
Shared Room in Teakettle or Midway Lodges (2 people/room, both people must request 2 people/room) +$50
Single room in Teakettle or Midway Lodges +$135
Reserve a room in Glacier Mountain Lodge +$210
Stay with someone in Glacier Mountain Lodge (no additional fees)
I will be staying off-site and don't need a room
12
Tentative Cost of Premium LodgingIf the person later decides that they want a single room because they are sensitive to roommate snoring, fragrances, light left on, etc, this field is gets the cost prior to decision
13
Roommates for Teakettle or Midway Lodges
I know who I would like to share a room with
I will decide later because I don't know who's going yet
I like meeting new people, please assign my roommates
14
Who would you like to share a room with?* This field is required.You can always change your mind later on
15
Glacier Lodge RoommatesI am reserving a room in Glacier Lodge. I would like my roommate(s) to be. You can always change your mind later on.
16
I am staying in Glacier Lodge. The person reserving the room is
17
Emergency Contact's Name* This field is required.
First Name
Last Name
18
Relationship* This field is required.
Please Select
Please Select
Adult Child (Son or Daughter)
Friend
Babysitter/Nanny
Sibling (Brother or Sister)
Mother
Father
Grandparent
Aunt
Uncle
Other
19
Phone Number* This field is required.
Area Code
Phone Number
20
Special Dietary NeedsWe will do all we can to work with you on your special needs. However, in extreme cases we may be unable to guarantee satisfactory compliance.
None
Gluten Free / Gluten Sensitive
Vegan
Vegetarian
21
DisabilitiesWe readily accommodate problems with stairs or the need for a handicap room. Please let us know about anything else
No Stairs
Handicap Room
Seeing Eye Dog
22
Roommate Selection
I am sensitive to fragrances
I need a dark room without a light on
I am sensitive to roommate snoring
23
Would you like a private room after all?
Yes - Additional $135 for a private room
No or "I'll think about it and get back to you"
24
Cut off for early, early bird discountThese dates must all be in the right order!!! Last day: 3/31/23
Date
Month
Day
Year
00
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Hour
00
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
25
Cut off for early bird discountLast day: 4/30/2023
Date
Month
Day
Year
00
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Hour
00
00
10
20
30
40
50
Minutes
26
First Day of Promo
Date
Month
Day
Year
00
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Hour
00
00
10
20
30
40
50
Minutes
27
Last Day of Promo
Date
Month
Day
Year
00
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Hour
00
00
10
20
30
40
50
Minutes
28
Today
Date
Month
Day
Year
29
These Dates Must be in the Right Order!!!

Early, Early Bird cut off date: {earlyEarlyBirdCutoffDate}

Early Bird cut off date: {earlyBirdCutoffDate}

First day of Promo: {firstDayOfPromo}

Last Day of Promotion: {lastDayOfPromo}

Today: {today}
30
Congratulations, you qualify for the Early, Early Bird Discount!* This field is required.Sign up now for best pricing!
Early, early bird discount. Pay by March 31 and save $25!
I want to take only the early bird discount of $15 for signing up by April 30
I don't want to take this discount.
31
You qualify for the Early Bird Discount!* This field is required.
Early bird discount. Save $15 by signing up by April 30.
I don't want to take this discount.
32
It's too late to get an early bird discount :-(
It's too late for this discount
33
Total Early Bird DiscountUse Conditional Logic to calculate this. Couldn't get max () to work. This excludes any special promo discount.
34
Coupon CodeUsed for special promotion. Enter the code here
35
Form Calculation Widget of Coupon CodeNeeded to make logic work. If you want to update the code, use the previous question
36
Amount of Promo DiscountIn Dollars
37
Special Promotion!We are offering a special promotion for people who have been wanting to come but were hesitating. Did your friend receive an email with a special coupon code. Enter the coupon code here to get the discount!
38
Form Calculation Widget of User-Provided Coupon CodeNeeded to make logic work
39
Congratulations! You are getting our special promotion of ${Promo_Discount}.00.
40
Oops. Your code was incorrect. Click "Previous" at the bottom left to try again, or click "Next."
41
Scholarship FundIf the Lord has blessed you with abundance, you may add to our scholarship fund to help those with financial difficulties attend the retreat. Please select one or more of the amounts below to add to your total due. We will make certain that 100% of your contributions will go directly to those in need of assistance. May the Lord bless you for blessing others!
$10 to be a blessing to someone
$25 to help out where there is need
$50 to help scholarship a single
$75 to the financial assistance fund
$100 to bless others as I have been blessed
42
Total Scholarship
43
Promotional Discount
44
Total Cost of Premium Lodging (Including Later Choice of Private Room)
45
Total Due
46
Lake McDonald CruiseGlacier National Park limits the number of cars allowed to enter the park during the hours we want to visit. Although their vehicle reservation system doesn't work well for us, they provide passes for people using services such as Lake McDonald cruises. We typically reserve a cruise on Lake McDonald on both Saturday and Sunday to facilitate park entry. The cost will be approximately $25/person with a minimum of 25 guests to charter the boat each day. We are asking about this for planning purposes only, Payment will be at a later date.
I would like to go on the cruise
I am undecided about going on the cruise
I don't want to go on the cruise but will gladly scholarship someone else so that everyone can get into the park
I will not be joining the group on the cruise either day

How much do I need to pay?

All costs are in USD.

Standard Registration	$175.00
Early Bird Discount	${totalEarlyBirdDiscount}.00
Premium Lodging	${totalCostPremiumLodging}.00
Scholarship to help another camper	${totalScholarship}.00
TOTAL	${totalDue}.00

48
I would like to
Mail in a check or money order
Pay On-Line
49
Payment Received
50
Comments on Payment Received
Huge
Large
Normal
Small
Ok
Ok
51
Not comingHidden field for people who decided to not come
YESNO
52
Your check or money order in the amount of ${totalDue}.00 should be payable to Christian Singles PULSE. Mail to

Christian Singles PULSE

3921 N 19th Street

Coeur d'Alene, ID 83815

It must be post marked by February 14 to get the early, early bird discount and by April 14 to get the early bird discount.
53
On-Line PaymentSecure Processing
prevnext( X )
2022 Christian Singles Retreat Registration
USD
+ OR enter a custom value
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Should be Empty: