Retreat Registration

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Name of Pastor *

First

Last

Pastor's Cell Phone Number *

Email *

Wife's Name

First

Last

Congregation(s) Name(s) *

Congregation City *

PayPal Phone Pastor's

Congregation State *

Room Preference *

List any food allergies or medical accomodactions needed.

Choose one from drop down list. *

PayPal Commerce *

Card Number

Expiration Date

Security Code

Card Holder Name