Register for Retreat

Tickets	Price	Fee
Retreat Ticket	$60.00	$0.00

Total: $0.00

Scholarship Request

Total

$0.00

Registration Info

First and Last Name

Cardinal ID Number:

CUA Email:

Year at CUA

Dietary Restrictions

Allergies

Health Insurance Provider

Policy Number

Insurance Group Number (if applicable)

Emergency Contact First and Last Name

Emergency Contact Relationship to Participant

Emergency Contact Phone Number

Billing Information

Name

Credit Card

Visa
Mastercard
American Express
Discover

Address

Mobile Phone Number

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You will be my witnesses.

Register for Retreat

Retreat Ticket

Registration Info

Billing Information