registrationform

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(404) 717-5557

Rachel's Vineyard Registration Form

I am registering for the following retreat: *

October 11 - 13 , 2019 February, 14 - 16 2019 June 12 - 14 , 2019 October 9 - 11, 2019

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Are you on any medications? *

Yes (List below) No

List medications below: *

Do you need handicap accessibility *

Yes No

How many abortions? *

How many miscarriages? *

Prior help *

Bible Study Counseling Other

Explain type of help *

Religious Affiliation *

Are you currently a Veteran or currently serving in the military (active duty, guard or reserves? *

Yes No

Emergency Contact during retreat:

Name *

First

Last

Phone Number *

How did you hear about PATH? *

The total cost of the retreat is $225.00.

A deposit of $50.00 is required to reserve your place.

Balance must be paid in full one week prior to retreat.

Please submit payment online through PATH website

or mail check (no cash) to:

PATH Inc.

PO Box 501238

Atlanta, GA 31150

Submit

We respect your privacy. All correspondence to PATH is confidential.

PATH, Inc. is a registered 501(c)(3) nonprofit and Catholic based ministry which provides a safe place for all individuals suffering from post abortion trauma to grieve their loss and reconcile with themselves, others, and God. We have staff available via call or text at (404) 717-5557 and en español (470) 258-3433.

Copyright © 2020 PATH, Inc. All Rights Reserved.

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Rachel's Vineyard Registration Form

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