Once you click submit below you will be forwarded to the online payment page for $125. Thank you.
Confidential Participant Registration Information
Which Retreat would you like to attend?(*)
Is it okay to leave a message on home message machine? (*)
Is it okay to leave a message on cell message machine? (*)
How did you hear about this retreat? (check all that apply)
Time since your last abortion:
Any other reproductive losses, such as miscarriages, infertility, stillbirth?
If yes, please share briefly:
Do you practice your faith on a regular basis?
Are you currently taking any medications?
If Yes, Please list names and dosages:
Do you have any dietary needs the kitchen should know about?
If you have allergies please list them?
Please share your reflections on the following:
What makes you feel in need of and ready for the Rachel’s Vineyard retreat?
Verification: Please check the box next to “I’m not a robot” to show that you are a real person(*)
When you click submit, you will see a thank you page that tells you your submission has been successful