Abide Retreat Application
Sign in to Google to save your progress. Learn more
PROGRAM FOUNDATION
I am the vine, you are the branches.  He who abides in me and I in him, he brings forth fruit.  For without me, you can do nothing!  John 15:5

If you abide in Me and My Words abide in you, you will ask what you desire and it shall be done for you.  John 15:7
PERSONAL INFORMATION
Legal Last Name *
Legal First Name *
Preferred Name
Email Address *
Phone Number *
Please include your area code
Which Abide Retreat are you interested in attending *
Check all that apply
Required
ADDRESS INFORMATION
Street Address *
City *
State *
Zip Code *
Date of Birth *
MM
/
DD
/
YYYY
Marital Status *
Are you affiliated with any religion? *
(Christian, Buddhist, etc.)
Name of Spouse (if applicable)
Do you have children? *
What size t-shirt do you wear? *
(Adult Unisex Sizes Only)
What do you hope to receive from the program? *
EMERGENCY CONTACT INFORMATION
Emergency Contact Name *
Relationship with Emergency Contact *
Emergency Contact's Phone Number *
MEDICAL INFORMATION
Please bring a list of your medications with you in case of an emergency.
Do you have current medical issues *
PTSD, Depression, Anxiety, etc.
Do you require assistance while you are staying with us? *
(Assistance with dressing, bathing, eating, etc.)
In order to be ambulatory, do you require any of the following? *
Are you on a special diet required by your doctor? *
If a special diet is required, please explain.
Do you have any allergies? *
If you have any allergies, please explain below. *
Please add N/A if this does not apply
Do you use a CPAP machine? *
Are you able to participate in recreational activities *
Required
MILITARY INFORMATION
Are you or your spouse Military or a 1st Responder *
If yes, please clarify *
REFERRAL INFORMATION
Who referred you to our program? *
ELECTRONIC SIGNATURE
By typing your name below, you are stating that all the information you provided is true.
Signature *
Please type your legal name
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Roever Evangelistic Association.

Does this form look suspicious? Report

Google Forms