Life-Giving Wounds Retreat Registration Form
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Cell Phone Number
*
Age
*
18-22
23-29
30-39
40-49
50-59
60+
Street Address
*
City
*
State
*
Religious Affiliation
*
Catholic
Protestant
Unaffiliated
Other
Specify if "Other"
If Catholic, your Diocese
*
Please Select
Archdiocese of Los Angeles (Santa Barbara, Ventura, and Los Angeles counties including the Valley, South Bay, Long Beach)
Diocese of Orange (Orange County)
Diocese of San Diego (Oceanside, Chula Vista, Imperial Valley, San Diego)
Other/Unknown
Name of Catholic Parish or 'none'
*
Parents' Relationship Status
*
Divorced
Separated
Married with high conflict
Annuled
Cohabitation
Dissolution
Never married
Other
Your Relationship Status
*
Married
Engaged
Dating
Single
Divorced
Annulled
Annulled and remaried
Consecrated Religious
Priest
Prefer not to say
Seminarian or novice
Are any family members, significant others, or close friends attending this event with you? If yes, whom?
*
Yes
No
Others attending this event with you
Name of Emergency Contact
Phone # of Emergency Contact
Have you discussed your family wounds with a counselor, priest, or trusted friend? Yes, No , or Other
*
Do you feel emotionally and psychologically capable at this time to attend an event where strong emotional content about family life will be discussed, shared, and processed? (If you are seeing a psychologist, then please consult first with him or her about whether he or she believes it is a good idea for you to attend a peer group like this one.) Yes, No, or Other
*
Do you have any food allergies the retreat team should be aware of?
Is there anything else you feel would be helpful to share with the team leadership at this time?
Amount
*
prev
next
( X )
Double Occupancy Room
$
325.00
Single Occupancy Room
$
375.00
Commuter
$
125.00
Thank you for choosing to pay online. All payments are processed through PayPal. Payments can be processed with or without a PayPal account. Your payment will reflect as PayPal on your credit card statement. If you have any questions, please contact the Office for Family Life at (714) 282-4203 or lji@rcbo.org. Thank you!
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