Complete the Registration Form Our Lady of Divine Providence Retreat Registration Form Tell Us About Yourself Today's Date First Name: Last Name: Suffix: Street Address: City: State:Please select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau Postal Code: Country: Mobile Phone: Home Phone: Work Phone: Email: Additional Retreat Information Date of Birth: (MM/DD/YYYY) Occupation: Parish Name: Diocese: Marital Status:Please select... Married Single Divorced Widowed Religious If you are coming on retreat with your spouse would you prefer:Please select... Separate Housing Shared Rooms Religious Only:Please select... Brother Sister Consecrated Lay Clergy Only:Please select... Priest Deacon Length of Retreat Stay:Please select... 3 5 8 30 Other Please indicate the number of retreat days: (Non-standard retreat days must be approved) Religious Denomination: Have you previously been on retreat at the House of Prayer?Please select... First Time 2-5 years 6-10 years 10 or more years Retreat Experience in the past 3-5 years (hold down the CTRL key to select multiple values):Please select... First Retreat Guided Retreats Directed Retreats Guided & Directed Retreats Weekend Only All of the above Do you presently see a Spiritual Director?Please select... Yes No How often do you see a director?Please select... Once a month Every two months Once a semester Occasionally How comfortable are you with maintaining silence?Please select... Very Comfortable Somewhat Comfortable Comfortable Anxious Very Anxious Do you have a particular goal for the retreat? Health Concerns/Special Needs:NoneAsthmaticDiabeticFirst floor Preferred Due to AmbulationHearing AssistanceWalker DependantOther Other Health Concerns: Dietary Concerns:NoneGluten FreeMilk AllergyNo SugarPeanut AllergyShellfish AllergyVegetarian Multiple AllergiesOther Do you have a pacemaker or any other condition that our magnetic name tags may cause interferrence?YesNo Other or Multiple Allergies: Please Note: While it is important that we are aware of your dietary concerns, we regret that we are unable to accommodate each individual. Please be assured other food items will be available at each meal. Emergency Contact Information Emergency Contact Name: Emergency Contact Relationship: Emergency Contact Number - Work: Emergency Contact Number - Home: Contact Information
