Men's ACTS Retreat Online Registration

Participant Name *
Participant Name
Address
Address
Cell Phone Number
Cell Phone Number
Home Phone Number
Home Phone Number
Work Phone Number
Work Phone Number
Optional
Will you have any specific dietary, mobility or medical needs during the weekend? *
If yes, we will contact you about your special needs.
Fees *
You may pay online through the ACTS webpage at Online Payment or by cash or check to the church office. Make checks payable to "Sts. Simon and Jude" and note "Men's ACTS" on the memo line.
Medical Release and Liability Waiver
Emergency Contact Information
Contact Name *
Contact Name
Contact's Cell Phone Number
Contact's Cell Phone Number
Contact's Home Phone Number
Contact's Home Phone Number
Contact's Work Number
Contact's Work Number
If you have a Medical Condition such as allergies or prescription medications which may require special attention during the retreat, please make sure you have checked the appropriate space on the top section of this form and the Director will contact you to discuss the details.
By signing this electronically, you agree to the above release of the parties stated.