ACTS RETREAT FORM

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Name as you want it to appear on your nametag: Please enter valid data.

Parish (if not St. Mark): Please enter valid data.

Address Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Email REQUIRED Please fill out this field. Please enter an email address.

** EMERGENCY CONTACTS: We need numbers that can be reached during business hours as well as evening (please provide 2 emergency contacts)

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Relationship(spouse, son, daughter, parent, etc.): Please enter valid data.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Email REQUIRED Please fill out this field. Please enter an email address.

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Relationship(spouse, son, daughter, parent, etc.): Please enter valid data.

Email REQUIRED Please fill out this field. Please enter an email address.

Allergies: REQUIRED Please fill out this field. Please enter valid data.

Any special dietary, medical, or other special needs for the retreat weekend:

Age (check one) REQUIRED 21-29 30-39 40-49 50-59 60+ Please fill out this field.

T-Shirt Size (check one) Small Medium Large XL XXL XXXL

Please send your $260 registration fee, to the address below. Checks should be made payable to St. Mark ACTS. A $100 deposit will hold your spot if you are unable to pay in full when returning your registration form. Balance will be due in full by February 12, 2025. The retreat registration is on a first-come, first-serve basis. Cut-off date for a refund is February 19, 2025. We will be required to pay for all retreatants whether or not they are able to attend.

Mail registrations to: Bill Little, 1591 Meadowview Drive, Corinth, TX 76210