Weekend Registration Form
Please, fill out the form and submit it. A team member will contact you shortly after that. Submitting this form does not obligate you to participate. Your information will never be shared or used in any other way.
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Email *
Check the program you are registering for: *
First Name ( as you want to be called) *
Last Name *
Gender *
Date of birth (for the international office tracking) *
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Mailing Address *
Primary Phone Number *
Email address (put none if you don't have one) *
Marital Status *
If Separated, is there a possibility that you might reconcile?
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How long have you been single again? (months/years) *
Number of years married? *
Religious affiliation *
The ministry is affiliated with the Catholic Church but serves those of every faith background who are grieving the loss of an important relationship.  The weekend is very spiritual but not dogmatic; if you are not Catholic, you will NOT be invited to convert.  The program concludes with Catholic liturgy (it counts!).  Participants are invited, but not forced, to attend the Mass as a prayerful conclusion to the weekend.
Name of church/place of worship *
Number of children & ages
Do you have any dietary (diabetic, vegetarian, etc.) or physical limitations that we should be aware of so we can make the weekend as comfortable as possible for you?
If yes, note special accommodations needed.  There are stairs at some of the facilities that we use.
If you have any limitations, please share how we may best meet your needs
Are you taking any medications or do you have health problems that we should be aware of in the event of an emergency? *
If yes, specify the medication/health issue so we can help if needed.
Emergency Contact *
Name, Phone Number and Relation
Are you presently involved in any type of professional counseling? If yes, please inform your therapist before participating in our program. *
Do you know anyone else who will be attending this weekend? Do you know any of the team members that may be hosting the weekend? *
If you arrive at the weekend and realize there is someone there that you are acquainted with, please let a team member know as soon as possible.  
If you do know someone attending the weekend, what is their name?
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