Registration & Payment Random Payment Option Name* First Last Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email* Text or Videophone NumberText NumberVideophone NumberEnter Your Text or Videophone Number here:*Emergency Contact - Name* First Last RelationText Number*Retreat Theme Shirts (long sleeve) - Pick your size:SMLXL2XL3XLDo you want your name on the shirt?YES, add my name on the shirt - type name belowNO, I don't want my name on the shirtType your name as you want it printed on the shirt:Special Accommodation Need Accessibility Need Deaf-Blind Interpreter Special Diet (describe below) Special Diet (include what you cannot eat)ROOMIE(S) PREFERENCE:Which Retreat Lodging Would You Like To Stay?*[Select One]MaranathaWPWMARANATHA RETREAT OPTIONS*Maranatha - 2 Ladies - $205.00Maranatha - 3 Ladies - $155.00Maranatha - 4 Ladies - $135.00Maranatha - 5 Ladies - $95.00WPW RETREAT OPTIONS*WPW Lodge - 2 Ladies - $215.00WPW Lodge - 3 Ladies - $165.00WPW Lodge - 4 Ladies - $145.00WPW Lodge - 5 Ladies - $125.00Friday Dinner? Add $15.00Yes, I would like Friday Dinner - $15.00I would like to pay today (Min $5.00 - Max. $100.00)$5.00$10.00$15.00$20.00$25.00$30.00$40.00$50.00$60.00$70.00$80.00$90.00$95.00$100.00Your Total: $0.00 Pay by September 4, 2021 - If for some reason you cannot make it to retreat, let us know by September 4, 2021, and you will receive full refund. Debit Card/Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name CAPTCHA
