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Rachel's Vineyard Retreat Application

Confidential Participant Information

Todays Date
Year
Month
Day
Phone Type
Okay to leave first name only message?
Are you currently practicing your faith on a regular basis?
Are you currently taking any medications?
Do you have any special needs, disabilities, special dietary needs or allergies?
Are you allergic to incense?
Do you have problems hearing?
Do you have a visual impairment?

Emergency contacts info for Friday 5:00pm to Sunday 4:00pm

Do you have any questions or fears you would like addressed before coming?

List three things you would like to team to know about you below.

Are you comfortable in a spiritual setting?
Are you currently seeing a Psychiatrist?
Are you currently seeing a counseler?

If yes to the above questions, please fill in the following information

Do we have permission to contat them if needed?
Do we have your permission to have our councilor contact you?
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