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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

PATH, Inc. is a registered 501(c)(3) nonprofit program, fostering a process of compassionate healing and restoration
for women and men wounded by abortion. We have staff available at (404) 717-5557. En Español (470) 258-3433.

Copyright © 2017 PATH, Inc. All Rights Reserved.

Home
Who We Are
Begin your PATH to healing
For Men
NEWS/RESOURCES
- Resources
Donate
Contact Us

Rachel's Vineyard Registration Form

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