Men&#039;s Retreat Registration

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Preferred Nickname: Please enter valid data.

Street Address REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Email REQUIRED Please fill out this field. Please enter an email address.

Cell Phone REQUIRED Please fill out this field. Please enter a phone number.

Work Phone Please enter a phone number.

Name of Parish or Church Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Over 21 years old? REQUIRED Yes No Please fill out this field.

Marital Status REQUIRED Single Married Please fill out this field.

Name of Spouse or Significant Other Please enter valid data.

Phone Number Please enter a phone number.

Close Family or Friend Contacts

Contact #1

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Email REQUIRED Please fill out this field. Please enter an email address.

Contact #2

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Email REQUIRED Please fill out this field. Please enter an email address.

Have you ever attended an ACTS Retreat? REQUIRED Yes No Please fill out this field.

If yes, when and where?

Did someone invite you ? Please enter valid data.

Please "check" if any specific needs: Dietary Medical Physical Financial Assistance

If yes, please explain Please enter valid data.

Registration Fee REQUIRED 50.0 – Deposit (Due Now - Non-Refundable) 210.0 – Full Payment Please fill out this field.

Would you like to make a donation? $ Please enter a positive decimal.

St. Elizabeth Ann Seton
Catholic Church