Confidential Participant Registration Information MAY 26-28, 2023 GUGGENHEIM CENTER SARANAC LAKE, NY Questions? 518-524-0774 Once you click submit below you will be forwarded to the online payment page for $150. Thank you. First Name:(*) Invalid Input Last Name:(*) Invalid Input Street:(*) Invalid Input City:(*) Invalid Input Zip:(*) Invalid Input Email(*) Invalid Input Phone:(*) Invalid Input I am 18 years old or older.(*) I agree Invalid Input Is it okay to leave a message: (*) YesNo Invalid Input How did you hear about this retreat (check all that apply): Church bulletinWord of mouthPastor/priest/ministerWebsiteDiocesan NewspaperBrochure/PamphletOther Invalid Input Your age now: Invalid Input Number of Abortions: Invalid Input At what age(s): Invalid Input Time since your last abortion: Invalid Input Any other reproductive losses, such as miscarriages, infertility or stillbirth: YesNo Invalid Input Please share briefly: Invalid Input Religious background: Invalid Input Do you practice your faith on a regular basis: YesNo Invalid Input Are you currently taking any medications:(*) YesNo Invalid Input Please list names and dosages: Invalid Input Do you have any dietary needs the kitchen should know about: (*) Invalid Input Do you have any food allergies or any other allergies:(*) YesNo Invalid Input Please explain:(*) Invalid Input Emergency Contact Name:(*) Invalid Input Phone Number: (*) Invalid Input Relationship to you: Invalid Input Do you have someone at home who will support your continued healing or would you prefer a participant sponsor who has been through the program to support you: Invalid Input Please share your reflections on the following: What makes you feel in need of and ready for the Rachel’s Vineyard Retreat: Invalid Input
