Details:
Title:
*
Mr.
Mrs.
Ms.
Miss.
Rev.
Dr.
Gender:
*
Male
Female
Surname:
*
Given Name:
*
Name you would like to be called, if different from above:
Mailing Address:
*
Town/City:
*
Province/State:
*
Postal/Zip Code:
*
Country:
*
E-mail Address:
*
Home Phone:
*
Work Phone:
Cell Phone:
Please indicate your age group:
*
18 - 29
30 - 39
40 - 49
50 - 59
60 - 69
70 +
Marital Status:
*
Married
Divorced
Widower
Widow
Single
Spouse's Name: (if applicable)
Is your spouse attending a Cursillo weekend at this time?
Yes
No
n/a
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or
Has he/she attended a previous Cursillo weekend?
Yes
No
n/a
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Parish:
Church or Parish Name:
*
City:
*
Pastor or Priest's Name:
*
Are you Baptized?:
*
Yes
No
Sponsor:
Sponsor's Name:
*
Sponsor's Phone Number:
*
Has your sponsor explained the nature and purpose of the weekend?
*
Yes
No
Any Medical Conditions/Diet Restrictions?
Do you have any medical conditions or disabilities of which we should be aware, such as: allergies, special dietary requirements (i.e. gluten free) or inability to use stairs?
....
*
Yes
No
If Yes, please explain:
Agreement:
* Please be aware that there is a charge to attend the weekend, which covers the cost of all meals and accomodations. Your sponsor will be able to tell you the current rate.
I agree to have my name & contact details included on a Cursillo weekend list/mail-out:
*
Yes
No
Please type in your name to confirm this application:
*
Date:
*
-
Month
-
Day
Year
at
/
Hour
Minutes
AM
PM
Please provide any additional comments in the space allocated:
Please hit the Submit button below to send in your Application
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