Pay On-Line Registration Form

• Please provide the following contact information:

  First Name	Mrs.Ms.Miss
  Last Name
  Middle Initial
  Street Address
  City
  State
  Zip
  Congregation
  Work Phone
  Home Phone
  Cell Phone
  E-mail

Select all of the following options that apply:

Married            A Minister's wife  An Elder's wife    A Deacon's wife  
Widow              Divorced           Single             Single Parent

Youth  (Age)

Choose your shirt size         ..........Shirt Size.......... Small Medium Large XL 2-XL 3-XL 4-XL

Do you plan to attend the Friday AM Session? 
.....Choose One.....
Yes
No

Have you made reservations? 
...Choose One...
Yes
No

Did you attend the 2011 retreat? 
..........Choose One..........
Yes
No

Referred by:  

If not, please do so.  Rooms tend to reserve quickly. Remember, you can always cancel.  

 Anticipated Arrival date.

Method of Payment	Name On the Card!
..........Choose One!..........VisaMaster