Personal Information:
Full Name (First and Last)
*
Preferred Name
*
Age
*
Shirt Size
*
Small
Medium
Large
X-Large
XX-Large
Other
Shirt Size Holder
Phone Number
*
Email Address
*
example@example.com
Marital Status
*
Single
Married
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
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California
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Connecticut
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District of Columbia
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Maine
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Ohio
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Tennessee
Texas
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Vermont
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Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
I am a registered member of
*
St Charles
Other
Denomination
*
Spouse’s Name
*
Spouses Phone Number
Parish Holder
Financial difficulties should not prevent anyone from attending this retreat. If you have financial concerns, please click here and the Parish Office will contact you so that confidential agreements can be made.
*
Please Select
Yes, I would like the Parish Office to contact me.
No, I don't need the Parish Office to contact me.
Financial Assistance is needed
Additional Considerations:
Allergies
*
Dietary Needs
*
Smoking Preference
*
Smoking
Non-Smoking
Medical Concerns
*
Emergency Information:
Emergency Contact
*
Relationship of Contact
*
Emergency Contact Phone Number
*
Emergency Contact Cell Number
*
Emergency Contact that does not live with you
*
Relationship of Contact
*
Emergency Contact that does not live with you Phone Number
*
Deadline
to return application
to the parish office
is 4 pm
Thurs
day,
June 13
th
.
Deposit and full payments Only
*
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Men's ACTS Deposit
$
60.00
Men's ACTS Retreat Payment in full
$
170.00
Credit Card
Submit
Should be Empty: