Our Lady of Perpetual Help
Retreat and Spirituality Center

Diocese of Venice, FloridA

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Payment for Pre-arranged Retreat

If you have already arranged an individual retreat with an OLPH staff person
and have been directed to this page, please continue below to make your payment.
The maximum number of form submissions has been reached. This form is currently not available.
- This page is used only for retreats and other payments previously approved by OLPH.
- ----- RETREATANT INFORMATION -----
- Retreatant's First Name REQUIRED Maximum 20 characters Please fill out this field. Please enter valid data.
- Retreatant's Last Name REQUIRED Maximum 35 characters Please fill out this field. Please enter valid data.
- Retreatant's Street Address REQUIRED Please fill out this field. Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Email REQUIRED
  Please enter the email address to use for OLPH correspondence
  Please fill out this field. Please enter an email address.
- Phone Number REQUIRED Maximum 20 characters
  Please enter the best 10-digit phone number (including area code) to reach you.
  Please fill out this field. Please enter a phone number.
- Date of Birth REQUIRED
  Please enter your Date of Birth in MM/DD/YYYY format.
  Please fill out this field. Please enter a date.
- Enter Retreat/Event Name and Date REQUIRED Please fill out this field.
- Are you Catholic? REQUIRED Yes No Please fill out this field.
- If you are of another faith, please specify. Maximum 60 characters Please enter valid data.
- Please identify if you are a priest, deacon, seminarian, or religious.
  Please select the option that applies to you.
- If you selected Other above, please specify: Maximum 60 characters Please enter valid data.
- ____________________________________________________________________________
  ----- EMERGENCY CONTACT INFORMATION -----
- This information is to help us, as well as to provide EMT and health care professionals with important information in case of a medical emergency.
  Please note: EMTs are trained to ask questions about a person’s age, current medication, emergency contact numbers, and important medical history.
- Emergency Contact Name REQUIRED Please fill out this field. Please enter valid data.
- Emergency Contact Relationship REQUIRED Please fill out this field. Please enter valid data.
- Emergency Contact Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- ___________________________________________________________________________
  ----- HEALTH INFORMATION -----
  (Must be completed unless you have previously submitted your application for this retreat.)
- OLPH is limited in its ability to accommodate special dietary needs.
- (1) Please identify if you have any food allergies or medically-required dietary restrictions. Please note that OLPH is limited in its ability to accommodate special dietary needs. We CANNOT accommodate Vegans.
- (2) Please identify any medical conditions that you would like us to be aware of that would help Emergency Health Care Workers treat you should you be unable to communicate with them.
- (3) Please identify any prescription or non-prescription drugs (and dosage) which you are currently taking that you would want an Emergency Health Care Worker to be aware of if you were unable to communicate.
- (4) Please identify if you are presently involved in regular psychological therapy. If so, how long have you been in counseling and how often do you meet?
- ____________________________________________________________________________
  ----- RETREAT HISTORY AND EXPECTATIONS -----
  (Must be completed unless you have previously submitted your application for this retreat.)
- (5a) Have you ever made a Directed Retreat? Yes No
- (5b) If yes, please identify most recent dates, type of retreat, and duration.
- (6a) Are you presently in Spiritual Direction? Yes No
- (6b) If Yes, how long have you been in direction and how often do you meet?
- (7) What reasons do you have for wanting to make a retreat at this time?
- (8) What desires, hopes, fears or concerns do you have for this retreat?
- (9a) Have you done any theological studies? If yes, please specify.
- (9b) Have you done any scripture studies? If yes, please specify.
- ____________________________________________________________________________
  ----- PAYMENT INFORMATION -----
- Payment Type REQUIRED Please fill out this field.
- Payment Amount (you will have the option of paying by debit card, credit card, or eCheck): REQUIRED $ Please fill out this field. Please enter a positive decimal.
- Registration is not complete until you
  Proceed to Payment
Total:

Submit

Proceed to Payment
- Stewardship & Memorial

Payment for Pre-arranged Retreat

----- RETREATANT INFORMATION -----