Name :   First Last

Address :   Street

City   State   Zip

Home :   Area Code & Phone Number :   - -

Business :   Area Code & Phone Number :   - -

E-mail Address :

Current church/parish affiliation :  (for statistical purposes only)

I would like to register for the following retreat :   (List retreat date or parish name)

Have you previously attended a retreat at Ignatius House? Yes No

Our facility has two floors and no elevator. Do you have a physical/medical condition
requiring a room on the ground floor?   Yes No