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PilgrimRenewal

Your Name (required)

Address (required)

City (required)

State (required)

Zip (required)

email (required)

phone (required)

Marital Status (required)

MarriedDivorcedSingleWidowed

Spouse Name

Spouse Phone

Number of Children

Name (required)

Phone (required)

Relationship

Occupation

Education

Date of Birth

Church Name

Pastor/Priest/Minister's Name

Denomination

Church Address

Church City

Church State

Church Zip

Date

Location

MenWomenCoed

Sponsor's Name (required)If you don't have a sponsor, enter 'I Need One'.

Sponsor's Phone

Sponsor's email

Name to be used on name tag

Do you have any special dietary requirements?

YESNO

What kind of dietary requirements?

DiabeticVegetarianLow SaltGluten FreeOther:

Do you require medications at specific times each day?

YESNO

Do you have any health or physical restrictions that require special equipment or facilities?

YESNO

If you answered "YES" to the above medical questions, Please give us some details so that we may assist you on YOUR weekend. If you want someone to call you regarding special needs, please let us know.

Please talk to your sponsor regarding the cost of the week-end. If you are paying for the weekend, the cost is $120 (This includes the $20 application fee). You can conveniently use the PayPal 'Donate' on the right edge of this page towards to top to pay. If you can not pay for the week-end please talk it over with your sponsor. Additionally, there are scholarships available, contact the Pre-Weekend Chair for more information.