Application for the Fall 2021 Silent Retreat at Mother Cabrini Shrine - October 27-31, 2021
Applications for this retreat will not be processed until after July 1st.

The application requires a 50% deposit which may be paid by check or credit card. Payment instructions provided at the end of the application.

NOTE: to ensure that you receive our retreat updates, please add mail@flocknote.com to your address book.
Sign in to Google to save your progress. Learn more
Applicant's Name: *
Applicant's Email Address: *
Applicant's Telephone: *
Applicant's Mailing Address: *
City, State, Zip *
Retreat Length: *
Required
Emergency Contact Name: *
Emergency Contact Relationship: *
Emergency Contact Phone Number: *
For a Better Appreciation of Your Personal Spirituality
[All this information will be kept confidential]
Have you made a silent retreat before? *
Was it personally directed or guided? *
Are you currently in spiritual direction? *
What prompts you to make this retreat? *
What desires, expectations, hopes, fears or concerns do you have for this retreat? *
What have been some of the major influences affecting your personal life/spirituality? And how have they affected you? (Example: Parents/Family) *
Favorite/Scripture/Passages: *
 Moments of major decisions (Vocation/Change/Conflict) Conversion Experiences: *
What is your present ministry/occupation *
Religious Affiliation *
Required
Check One: *
Date of Birth: *
MM
/
DD
/
YYYY
What Parish do you attend? *
Medical Information Section
Are there any past or current medical conditions or information that we need to be aware of? *
Are there allergic conditions that we need to be aware of? (Including medication allergies): *
Do you currently take medications? If yes, please list medications: *
Will you have any special needs during this retreat? If yes, please explain: *
Do you have medical background/training? If yes, please explain: *
Alternate Emergency Contact Name & Phone Number: *
Health Insurance Company: *
Health Insurance Phone Number: *
Policy Holder Name: *
Group Number: *
How did you learn about this retreat: *
Date of Application: *
MM
/
DD
/
YYYY
Signature: *
Instructions for completing the application:
* All applications will be reviewed by a staff member of the Lanteri Center    
* Refunds will be issued for those whose applications are not accepted at this time
* Check in is before 5 pm for orientation, schedule review and room assignment. Please make every effort to stay through the end of the retreat on Sunday afternoon

Please submit a 50% deposit with your application.

Instructions for payment will be presented on your screen after you press the SUBMIT button below.

Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of St. Ignatius Province Oblates of the Virgin Mary. Report Abuse
Google Forms