Via De Cristo Clergy Experience Retreat #1
Registration Form
Full Name *
Preferred Name for Nametag *
Mailing Address *
City *
Zip Code *
Home Phone
Cell Phone
Email Address *
Gender *
Age *
Marital Status *
Classification Registrant *
Home Congregation Name and City *
Medical, Dietary or Special Needs *
Emergency Contact Name (Someone not attending event) *
Emergency Contact Relationship *
Emergency Contact Cell Phone No. *
Emergency Contact Other Phone No. *
Emergency Contact Email *
I grant permission to Via De Cristo to create, copy, reproduce, exhibit, publish or distribute my image. I understand the above uses may include photographs, website, multimedia or promotional media existing now or in the future. I understand that the camp is drug free, and I promise to abide by this policy. *
Signature *
Date *
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