Address: 707 Main St. PO Box 225, Rochester, IN, 46975, US
Telephone: 574-223-5678

DUE: JANUARY 18, 2019

Confirmand Name*
First Last
Church & City*
Age*
Grade*
Gender*
To help in making room assignments.
Address*
Street Address Address Line 2 City State ZIP Code
Parent/Guardian Name*
First Last
Address (if different from above)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Parent/Guardian Contact 1
First Last
Parent/Guardian Contact 2
First Last
Emergency Contact*
First Last
Emergency Contact Phone*
Allergies
Medications
Special Dietary Needs
Option
Registration Fee*
Please return by January 18, 2019, the completed registration with the fee ($125.00 for the retreat - $75.00 deposit per person) payable either by Paypal or with a check payable to Presbytery of Wabash Valley • PO Box 225 • Rochester IN 46975-7382 (One entry per form)
- Deposit ($75.00 pp)
- Pay In full ($125.00 pp)
Payment Options*
- Paypal or Credit Card
- Pay by Check
Date*
Date Format: MM slash DD slash YYYY
Total
$0.00
Email
This field is for validation purposes and should be left unchanged.

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