Bellarmine Jesuit Retreat House · January 17

Name

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Prefix

First Name

Last Name

Suffix

How would you like your name to appear on your name tag and materials?

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Email

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Verify Email

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Cell Phone

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I would like a text reminder about this retreat.

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Landline (optional)

Address

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Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Birth Date

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To assist with room assignments, please enter your birthdate. (mm/dd/yyyy)

Gender

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To assist with room assignments, please enter your gender.

Please select ONE retreat contribution option.

Retreat Contributions *	Quantity
$100 - Non-refundable Deposit per Retreatant
$365 - Suggested Contribution per Retreatant

You have selected two options under Retreat Contributions. Please select only one option to proceed. Thank you.

I want to make an additional donation:

$

Emergency Contact Name

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Emergency Contact Relationship

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Emergency Contact Phone Number

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Are you part of a parish/church?

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Enter parish/church name

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Are you part of a retreat group?

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Enter group name

*

Do you have a room request based on medical needs?

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Yes

No

Please enter brief reason for room request, e.g. CPAP machine, limited mobility, etc.

*

Bathrooms are assigned based on age or medical needs. Only 20% of our rooms have ensuite bathrooms.

Have you attended a Bellarmine weekend retreat in the past three years?

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Yes

No

If the main retreat house building is fully occupied, are you willing to stay in our rustic cottage or coachhouse?

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Cottage

Coachhouse

No

If the main retreat house building is fully occupied, are you willing to stay in our rustic cottage?

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Cottage

No

Do you have any dietary restrictions?

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You are welcome to bring your own food. A refrigerator and microwave are available for your use.

None

Vegan

Vegetarian

Gluten free

Dairy free

Other

Other - Please enter information regarding any other food allergies.

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Retreat Registrant 2 Details

Registrant 2 Name

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First Name

Last Name

Registrant 2 Email

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Please enter the email address of this guest. Please do not re-enter your email address.

Verify Email

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Registrant 2 Phone (Cell preferred)

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Retreat Registrant 3 Details

Registrant 3 Name

*

First Name

Last Name

Registrant 3 Email

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Please enter the email address of this guest. Please do not re-enter your email address.

Verify Email

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Registrant 3 Phone (Cell preferred)

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Retreat Registrant 4 Details

Registrant 4 Name

*

First Name

Last Name

Registrant 4 Email

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Please enter the email address of this guest. Please do not re-enter your email address.

Verify Email

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Registrant 4 Phone (Cell preferred)

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Silent Retreat Registration

January 17 - 19, 2025
Our Father who art in Heaven…
Men's Retreat

Retreat Leader - Fr. Jim Flaherty, SJ

Retreat Registrant 2 Details

Retreat Registrant 3 Details

Retreat Registrant 4 Details

Payment Information

Silent Retreat Registration

January 17 - 19, 2025Our Father who art in Heaven…Men's Retreat

Retreat Leader - Fr. Jim Flaherty, SJ

Retreat Registrant 2 Details

Retreat Registrant 3 Details

Retreat Registrant 4 Details

Payment Information

January 17 - 19, 2025
Our Father who art in Heaven…
Men's Retreat