Retreat Registration (1 Person Per Submission)

SKU:

$260.00

Unavailable

per item

Your retreat registration fee covers lodging, meals, and program materials for one person. (If unable to pay registration in full at this time, limited scholarships may be available. To apply for scholarship, please select $50 deposit option below, or call 520-743-6777 for further guidance or assistance with the process).

Name: *

Mobile# (Do you authorize us to contact you using this number?): *

Email (Do you authorize us to contact you using this email?): *

Mailing Address: *

Present age? *

Preferred Retreat Date *

Emergency Contact during the retreat weekend: Name, Number, and Relationship? *

If married, is your spouse the father/mother of the aborted baby? *

Would he/she also like to participate on the weekend retreat? *

Do you have an allergy to incense or fragrances? *

Are you currently seeing a counselor or psychiatrist? If so, do we have permission to contact them, if needed? *

Name/Title of mental health professional? Contact number? *

Diagnosis of any Medical/Psychiatric Condition(s): *

Are you currently taking any medications? If so, please list them... *

Do you have any special needs/disabilities/special dietary needs/or allergies? If yes, please list them. *

Are you hearing impaired? *

Do you have a visual impairment? *

Number and date(s) of abortion? *

Have you kept your abortion(s) a secret? If not, who knows about your abortion(s)? *

Do you have any living children? If so, how many and what are their ages? *

Are you comfortable in a spiritual setting? *

What is your religious background? *

Are you currently practicing your faith on a regular basis? *

How did you hear about us? *

Were you referred to Rachel's Vineyard by Clergy? If so, list name and church below so we can thank them for their support. *

What do you hope to gain by attending the retreat program? *

Do you have any questions or fears you would like addressed before attending? *

Please take a moment and list (3) things you would like the team to know about you. *

Number and date(s) of miscarriage(s): *

Quantity

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$50 Non-Refundable Retreat Registration Deposit

DEPOSIT HERE