***Please print this form and complete all entries.  Then mail or Fax (charges only) with your deposit of $25.00 (or more) to the following address:

Our Lady of Florida Spiritual Center

1300 U.S. Highway #1

North Palm Beach, FL  33408

561-626-1300 - FAX 561-627-3956

RETREAT REGISTRATION FORM

**Please PRINT all information:

NAME:______________________________________________________________

ADDRESS:___________________________________________________________

CITY:________________________________________STATE:________________

ZIP:____________E-MAIL:____________________________________________

PHONE:(_____)______________Date Of Birth(MM/DD/YYYY)_______________

PARISH or K of C COUNCIL:__________________________________________

DATES OF RETREAT:__________________________________________________

Need Special Room?:_____________Special Diet?:_____________________

Have you made a retreat here in the past?:_________________________

I hereby authorize Our Lady of Florida Spiritual Center 

to charge my (check one)  VISA____MASTERCARD____AMEX____

ACCT NUMBER______________________________EXP.DATE(mm/yy)_____/_____

Name on Card_____________________Signature_________________________

Amount to Charge:  $_____.___  If card billing address is different from the above address, please check here ____ and write the credit card billing address on the back of this form.

Don't forget to include your deposit (or you may pay the full amount now).  Thank you!!

WE WILL NOTIFY YOU TO CONFIRM YOUR RESERVATION