Shalom Registration

	Name:
	Address:
	City:
	State:
	Zip:
	Phone:
	Email:
	Parish, Church, or Organization:

	Would you like to be added to the postal mailing list?	Yes No
	Would you like to receive a monthly e-mail from Shalom Retreat Center highlighting events happening during the next six weeks?	Yes No
	Would you like to register for a program/retreat? (if so, please fill out the questions below):	Yes No

	Program/Retreat Title:
	Date of Program/Retreat:
	Retreat Type:	Overnight Retreat Daily Commuter
	Physical Needs:
	Medical/Dietary Needs:
		*food allergies diagnosed by a physician (not food preferences). If you follow a vegan diet, you must call us at least one week in advance to discuss.

	If you are registering for a dinner program, please list the names of all those whom you wish to be seated with.
	How did you hear about this program/retreat?
	How do you intend to pay?	Check Cash Credit or Debit Card Money Order