Rachel's Vineyard Retreat Registration Form
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I am registering for the following Rachel's Vineyard retreat:

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Your First and Last Name: *
Street Name: *
City *
State *
Zip *
Phone Number *
Email address *

Do you have any special physical needs or allergies?     

 *
 If "YES", please list all here: *
Do you need handicapped accessibility? *

Are you currently on any medications? 

 *
If "YES", please list any and all medications here: *
How many pregnancies have you had? *
How many abortion/s?  Please provide date/s:  *
How many miscarriages have you had?  Please provide date/s: *
How many stillbirths have you had?  Please provide date/s: *
Do you have any children who have been placed for adoption or are in foster care?  Please provide date/s:  *
Please give a list of your past counseling/self-help group experiences if any:    *
Required
Are you affiliated with any religious denomination? *
If yes, what religious denomination are you affiliated with? 

If no, please indicate "N/A"
 *

Do you have any concerns, questions or fears you would like addressed before attending this Retreat?

 *

If yes, what are your specific concerns, questions or fears so that we may address them for you?   

If no, please indicate "N/A"

 *

What do you hope to gain by attending this Retreat?

 *

How do you define healing?  

 *
Are you currently a Veteran or currently serving in the military (active duty, guard or reserves)? *
EMERGENCY CONTACT INFORMATION:
Please list First and Last Name of your emergency contact during retreat: *
Please list phone number of your emergency contact: *
What is your emergency contact's relationship to you? *
RETREAT FEE and DEPOSIT:

The total cost of the retreat is $225.00 which includes your lodging, food/meals and retreat materials. 

You may pay $50.00 deposit to reserve your place prior to the retreat, or you may pay the $225.00 in full. 

You balance must be paid in full one week prior to retreat.

There are 2 options to pay your retreat fee:
1) Online
2)  Mail 
Please indicate below how you will be paying for the retreat:
OPTION #1:  I want to pay ONLINE through PATH secured payment page  

Please indicate below what you paid today:
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OPTION #2:  I want to pay by check or money order (no cash) in the amount of $225.    

**Please make check or money order payable to PAC and reference "PATH Retreat" on check

Mail to:
PAC
P.O. Box 92
Roswell, GA 30077 

Please indicate below what you paid by check today:
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How did you hear about PATH’s abortion healing program? *
Required
Thank you for completing this form!  

We will be in contact with you with you soon!

PATH/Post Abortion Treatment & Healing
www.healingafterabortion.org
Confidential email:  programdirector@pathatl.com
Phone:  404-717-5557
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