Retreat Registration Non-Refundable Deposit

SKU:

$50.00

Unavailable

per item

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? *

Married, Single, Divorced? *

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? *

Age at time of abortion(s): *

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? *

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

Any other losses? *

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

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

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