Esperanza Reconnect Registration
…making time and space to connect with God, your creator, the one who loves you more passionately and knows you more completely than anyone.

“You will seek me and find me when you seek me with all your heart. I will be found by you,” declares the Lord. Jeremiah 29: 13-14

Email address *
Name (first and last) *
Your answer
Mailing address *
Your answer
Birthdate *
MM
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DD
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YYYY
Why would you like reconnect with God at Esperanza? *
Your answer
What do you hope to get out of your time here? *
Your answer
This program is offered for one week (Monday- Friday) or for one weekend (Friday – Sunday). I would prefer to attend this program: (please check one) *
Since the nearest medical facility is a boat ride away, please list any medical conditions that we should be aware of (diabetes, allergies, etc.) or type "none". *
Your answer
Are you currently on any medications? Please list or type "none". *
Your answer
Do you have any mobility issues or special needs? *
Your answer
List the names and ages of those who would like to attend with you.
Your answer
Please check the following if you agree: *
Required
Emergency Contact Name *
Your answer
Emergency Contact Number *
Your answer
Contact information
Once we receive your registration form, we will contact you with available dates as soon as we can. Because of our remote location our internet and phone lines do not always work. Please provide us with at least two different ways of contacting you.
Preferred contact method (example: phone (250) 483-6991)
Your answer
Back up contact method
Your answer
Last resort contact method
Your answer
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