Women&#039;s ACTS Online Registration

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Address: REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Home Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Work Phone Number Please enter a phone number.

Cell Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Age Please enter valid data.

Email REQUIRED Please fill out this field. Please enter an email address.

Other Means of Contact Please enter valid data.

Marital Status: Married Single Widowed

Name of Spouse or a friend: Please enter valid data.

Spouse's or Friend's Phone Number Please enter a phone number.

Spouse's or Friend's Email Please enter an email address.

Name(s) of other persons (not going on the retreat) whom we can call to pray for you:

First Name Please enter valid data.

Last Name Please enter valid data.

Phone Number Please enter a phone number.

Email Please enter an email address.

First Name Please enter valid data.

Last Name Please enter valid data.

Phone Number Please enter a phone number.

Email Please enter an email address.

Emergency Contact Name REQUIRED Please fill out this field. Please enter valid data.

Relationship to Emergency Contact Please enter valid data.

Emergency Contact Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Emergencyt Contact Email REQUIRED Please fill out this field. Please enter an email address.

Have you ever attended a Women's ACTS Retreat? REQUIRED Yes No Please fill out this field.

If yes, when and where? Please enter valid data.

Parish or Church you attend? Please enter valid data.

City that your Parish or Church is located Please enter valid data.

Religion Please enter valid data.

Did someone invite you to this retreat? Yes No

If yes, who? Please enter valid data.

Will you have any specific dietary, medical, or physical needs during this weekend (i.e. prescription meds, trouble walking on the retreat grounds, etc.)? Yes, please advise a member of the ACTS Retreat Team. No

The registration fee is $250. I have included my nonrefundable deposit of $50 and I understand the balance is due on or before February 25, 2024 I will need financial assistance as I cannot pay all of the fee.

For further information email Michelle McClary at [email protected]

Please make checks payable to St. Justin Martyr and mail or deliver with this form to:
ACTS Retreat for Women, St. Justin Martyr Catholic Church, 13350 Ashford Point Drive, Houston, TX 77082-5100