WOCIC

Participant Registration Form

* Required Field

*Participant Name:	Female Male
* (Please select the correct date)

So We Can Contact You ...

*Street Address: *City: *St: *Zip:

Email Address:

*Home Tel# (include area code): Cell# (include area code):

Tell Us About Yourself ...

*Currently: *Your Age: How Many Children:

Spouse's Name:

What Church Do You Attend:

Who Referred You:

Please tell us of any special needs, including lodging, medical and meals:

Emergency Contact Information (just in case!)

*Emergency Contact Person:

*Relationship: *Phone# (include area code):

How Will You Pay?

*Please select how you will pay after you submit this form:

Mail a Check Pay Online

IMPORTANT NOTICES

Only full payments are accepted ... no deposits. All payments are non-refundable and non-transferable. If payment is not received with your registration form, your registration will not be processed. If you are paying by check, please complete this form, print it and send it with your check to:

WOCIC

11523 Palm Brush Trail #333
Bradenton, Florida 34202

Also, please note that the retreat center is a non-smoking facility.

If you have a question, you can contact us by phone at 941-746-7214 or by email by clicking <here>.

*Please Enter Your Initials To Confirm That You Read This Section & Accept These Conditions:

Please Sign Application ...

Note: if you are completing this form for someone else, please make sure that they are aware and approve!

*Please Enter Your Name (person filling out the form):

*Today's Date (mm/dd/yy):

If the applicant is 18 or younger, you must have your parent's or guardian's approval to attend an Encounter weekend ... please enter your initials to confirm you have done so:

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Please review your data before clicking on the Send button

We recommend that you print this page before you submit it ... PRINT NOW