USE TAB KEY TO NAVIGATE THROUGH FORM

RENEWAL 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, 1) what, 2)where, and 3)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 ) 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  Weekend:    
To see schedule of upcoming weekends click here

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) When you click the submit button below, your application should be forwarded to Randy Poisel, our (Candidate + Sponsor), Pre-Weekend Coordinator.  

3) A check for the weekend in the amount of $135 is required with each application.  Your check will not be processed until it is confirmed you will be able to attend the weekend.  Please send your check to: Randy Poisel  7703 Home Drive, Fishers, IN 46038  Phone: 317-576-0627