retreatregistrationform

Rachel's Vineyard Weekend Retreat
Registration Form

I am registering for the following Rachel's Vineyard retreat: *

February 25 - 27, 2022 June 10 - 12, 2022

* 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:

Emergency Contact First Name & Last Name *

First

Last

Emergency Contact 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 e-Giving or please mail check (no cash) to:

PATH
PO Box 92
Atlanta, GA 30077

Submit

Rachel's Vineyard Weekend Retreat ​Registration Form

Rachel's Vineyard Weekend Retreat
Registration Form