Diocese of Ogdensburg

The Roman Catholic Church in Northern New York

Questions? 518-891-2309 or 518-524-0774 Once you click submit below you will be forwarded to the online payment page for $125. Thank you.

Confidential Participant Registration Information

Which Retreat would you like to attend?
Invalid Input

Full Name
Invalid Input

Street
Invalid Input

City
Invalid Input

Zip
Invalid Input

Email
Invalid Input

Home Phone
Invalid Input

Cell Phone
Invalid Input

Is it okay to leave a message on home message machine?
Invalid Input

Is it okay to leave a message on cell message machine?
Invalid Input

How did you hear about this retreat? (check all that apply)
Invalid Input

Your age now
Invalid Input

Number of Abortions
Invalid Input

At what age(s)
Invalid Input

Time since your last abortion:
Invalid Input

Any other reproductive losses, such as miscarriages, infertility, stillbirth?
Invalid Input

If yes, please share briefly:
Invalid Input

Religious background:
Invalid Input

Do you practice your faith on a regular basis?
Invalid Input

Are you currently taking any medications?
Invalid Input

If Yes, Please list names and dosages:
Invalid Input

Do you have any dietary needs the kitchen should know about?
Invalid Input

If you have allergies please list them?
Invalid Input

Emergency Contact
Name:
Invalid Input

Phone Number:
Invalid Input

Relationship to you:
Invalid Input

Do you have someone at home who will support your continued healing or would you prefer a participant sponsor who has been through the program to support you?
Invalid Input

Please share your reflections on the following:
What makes you feel in need of and ready for the Rachel’s Vineyard retreat?
Invalid Input

Verification: Please check the box next to “I’m not a robot” to show that you are a real person
Invalid Input

When you click submit, you will see a thank you page that tells you your submission has been successful