Our Lady of Divine Providence Retreat Registration Form
Today’s Date
First Name:
Last Name:
Suffix:
Street Address:
City:
State:
Postal Code:
Country:
Home Phone:
Work Phone:
Mobile Phone:
Email:
Date of Birth: (MM/DD/YYYY)
Occupation:
Parish Name:
Diocese:
Marital Status:
If you are coming on retreat with your spouse would you prefer:
Religious Only:
Clergy Only:
Length of Retreat Stay:
Please indicate the number of retreat days: (Non-standard retreat days must be approved)
Religious Denomination:
Have you previously been on retreat at the House of Prayer?
Retreat Experience in the past 3-5 years (hold down the CTRL key to select multiple values):
Do you presently see a Spiritual Director?
How often do you see a director?
How comfortable are you with maintaining silence?
Do you have a particular goal for the retreat?
Health Concerns/Special Needs:
Other Health Concerns:
Dietary Concerns:
Other or Multiple Allergies:
Please Note: While it is important that we are aware of your dietary concerns, we regret that we are unable to accommodate each individual. Please be assured other food items will be available at each meal.
Emergency Contact Name:
Emergency Contact Relationship:
Emergency Contact Number – Work:
Emergency Contact Number – Home:
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