Women's ACTS

February 28 - March 3, 2019

St. Philip the Apostle Catholic Church

Women’s ACTS Retreat Application

This application is for registered St. Philip the Apostle parishioners only. Registration fee for parishioners is $150.00 and must be paid in full when using online registration.

If you are not a registered parishioner at St. Philip, or if you are a registered parishioner and wish to make payments ($50 deposit required), you can register by stopping by the office for an application during normal business hours (M-F 8:30am – 5pm). You can also request that an application be emailed to you by emailing the director at actswomen@stphilipcc.com. Registration fee for non-parishioners is $175.00.

Retreatant Information

Name

Title

First Name*

Last Name*

Preferred Name

Required*

Address

Street 1*

Street 2

City*

State*

Zip*

Preferred Phone

We will use this number as the main telephone contact number. It will not be made public.* --

Secondary Phone

E-mail

Date of Birth

Required* //

T-Shirt Size

Required*

Marital Status

Required*

Parish

If you are not associated with a parish, write NONE.*

Emergency Contacts/Health

Emergency Contact #1

First Name*

Last Name*

Phone

Required* --

Relationship

Required*

Emergency Contact #2

Phone

Relationship

Do you have health issues requiring a special diet?
Required*

We will alert caterer of your specific health needs.*

	Yes
	No

Do you have health issues, disability/conditions, or required medications that would affect your participation during the retreat?
Required*

	Yes
	No

If "Yes" to either question above, please explain:

Payment

Payment in full required to register online. Registered Parishioners only.

Order Summary

Subtotal
Discount
Sales Tax
Shipping & Handling
Total

Payment Type Credit Card

Credit Card

Name on Card
First Name*	Last Name*

Card Number* - - -

Accepted Types

Security Code (CVV2)* | What's this?

Expiration Date*

Billing Address

Street 1*

Street 2

City*

State*

Zip*

Provide the billing address

Phone Required* -- Provide a contact phone number for the billing contact.

Spam Capture

Photography Consent

I understand that photos and video (individual and group) may be taken during the ACTS Retreat, and I give permission for my picture to be used for printed or online promotional materials. I understand that I am responsible to ensure I am not in any pictures or videos for which I have not consented.

Photography Consent
Required*

	I AGREE
	I DISAGREE

Liability Waiver

I agree on behalf of myself, my heirs, successors, personal representatives and assign to protect, indemnify, save, and hold harmless the Diocese of Corpus Christi, St. Philip the Apostle Catholic Church and their officers, directors, agent,s employees, or representatives associated with the parish adult faith formation program from all damages, claims, suits, expenses and payment on account of or resulting from conditions stated on or resulting from any such injury, death, or damage to property, including resulting from the negligence of the Diocese of Corpus Christi, and parish, and or their officers, directors, and employees arising from or in connection with my attending adult faith formation events beginning July 1, 2018 and continuing through June 30, 2019.

Liability Waiver
Required*

Consent required to participate in retreat.*

I AGREE

Facebook Twitter Pinterest Google+ Instagram