Diocese of Springfield in Illinois

STEP ONE
ENTER INFO
STEP TWO
CONFIRMATION
STEP THREE
RECEIPT

Thank you for registering for the VESSELS Day of Reflection for Women with the Diocese of Springfield in Illinois. Please fill out the form below and if you have any questions, please reach out to Sr. M. Clementia at ctoalson@dio.org.

Qty

Description

Amount

Total

Registration

$35.00

Administrative Code (if applicable-office use only)

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I would like to sponsor another woman.

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Total: $35.00

Your Information

First Name: *

Last Name: *

Billing Address: *

This is the address where your credit card statements are mailed.

Address 2:

City: *

State / Province: *

Zip Code: *

Country: *

Email: *

A receipt will be emailed to this address.

Phone: *

Age: *

Parish Name: *

Parish City: *

Dietary needs or allergies:

How did you hear about this retreat? *

If other, please let us know where you heard about the retreat:

Retreat Experience: *

Emergency Contact Information

Contact Name: *

Contact Relationship: *

Contact Phone Number: *

Contact Email Address: *

Please list any medical conditions or medications you would like us to know of in case of emergency:

Your Payment Information

Name on Card:

Card Number:

Security Code:

Expiration Date:

Name on Account:

Routing Number:

Account Number: