Directed Retreat Reservation Form

Directed Retreat Reservation Form
Name: *

Prefix First Name Last Name
Date of Birth:

Month Day Year
Date

Address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Day Phone Number: *

Area Code Phone Number
Evening Phone Number:

Area Code Phone Number
Email:
example@example.com
Parish or Church:
Arrival Date: *

Month Day Year
Date
Arrival Time: *

: Hour Minutes AM/PM Option
Departure Date: *

Month Day Year
Date
Departure Time: *

: Hour Minutes AM/PM Option
For health reasons only, I prefer a room:
Do you have any Extreme Food Allergies; Health Issues (e.g. Diabetes, Celiac) - Not Food Preferences? If so, please explain:
Have you made any individually directed retreats before? *

Yes No
If Yes, Date of last retreat:

Month Day Year
Date
Are you presently involved in regular spiritual direction? *

Yes No
Religious affiliation:
What is your present ministry or occupation?
What characteristics or qualities are you looking for in a director?
We try to honor your request for a specific director whenever possible; to assist us in assigning directors, let us know if you have a preference:
We require a $50.00 non-refundable deposit at the time of registration. Your deposit is applied to the final balance of your payment.

If you are making an 8-day retreat, we also give you the option to pay for your entire 8-Day retreat ($880.00) up front if you so desire.

If paying by check please mail your payment to:

Sacred Heart Retreat House
Reservations Coordinator
P.O. Box 185
Sedalia, CO 80135

When paying by check please print out a copy of your reservation receipt and include it with your check. This will guarantee that your deposit is properly credited to you.

(Please note that if you pay by check your registration will not be complete until we receive your payment.)

If you would like to pay by credit card now, please use the form below and choose only one option.

To pay by credit card please choose ONE OPTION below:

Directed Retreat Non-Refundable Deposit $ 50.00

8-Day Directed Retreat Full Payment $ 880.00

Total $ 0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Should be Empty: