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CANDIDATE INFORMATION
Name:     
Home Phone: Work Phone:

Address:     
City: State: Zip:

E-mail address:                  
Date of Birth:

Your Occupation:  
Education:

Name to be used on your nametag:

MARITAL/SPOUSE INFORMATION

Marital Status:Single       Married    Divorced        Widowed   
Number of Children:

If Married, has your spouse submitted an application:  Yes   No
Spouses Name:    
  Spouse Phone:

EMERGENCY CONTACT INFORMATION

Family member other than Spouse to contact in case of emergency:

Name:       Relationship:   
Home Phone: Work Phone:   Cell Phone:

CHURCH INFORMATION

Church you attend:  
Denomination:

Address:
City: State: Zip:

Your Pastor/Priest/Minister's Name:  
Phone:

Have you discussed attending this Via De Cristo weekend with your Pastor/Priest/Minister?
Yes    No

Have you ever attended a 3-day retreat before?  Yes    No  
(Example: Via De Cristo, Cursillo, Great Banquet, Way of Christ, Kairos,  etc.) 
If yes, what, where and when did you attend:

MEDICAL INFORMATION

You will be fed very well while at the retreat. Do you have special dietary requirements which the cooks should know?
 No     Yes: (diabetic, low salt, etc.)

Do you require medications at specific times each day? No     Yes 

Do you have any health or physical restrictions that require special equipment or facilities? (Braille literature; hearing, vision, or walking difficulties)
No     Yes, explain

SPONSOR INFORMATION

Sponsor Name:   
Sponsor Phone:

choose one Yes No Are you aware there will be no contact with your family, except emergency?
choose one Yes No Has your sponsor discussed the cost ($115 + $20 application fee) of the weekend?
choose one Yes No Has your sponsor discussed the weekend accommodations with you?
choose one Yes No Has your sponsor discussed appropriate packing and clothing with you?

WEEKEND INFORMATION

I wish to attend a Via De Cristo : Please select one Spring weekend in the North Spring weekend in the South Fall Co-ed Central Fall Co-ed - Camp Pyoca, Nov 9-12 Spring weekend - no site preference Fall weekend - no site preference North weekend (next opportunity) South weekend (next opportunity) Next opportunity (no preference)

Additional Comments:

IMPORTANT  BEFORE YOU CLICK 'SUBMIT'!
1) Please click here to send an email and let Randy know your application is on the way.  We've had some technical difficulties and this will make sure he is aware you've submitted yours. List your name, your phone number, your sponsor's name and the weekend you wish to attend in the email.  

 2) If you have completed the form correctly, you will see a "form confirmation page".  If you don't see the "form confirmation" page, something has happened and you should re-submit it.  It's better for us to receive duplicate applications than to not receive one at all.  
             
In order for your application to be processed, you will also need to submit a $20 application fee.   See below. Use your "back" button to return to this page.