Our Lady of Perpetual Help
Retreat and Spirituality Center

Diocese of Venice, FloridA

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5-Night Retreat Registration

- Retreats
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    5-Night Retreat Registration
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    Hosting a Group Retreat
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Retreat Description
- 5-Night Retreat
Contact Us
- Denise Riley
  
  941-486-0233
  rileyolph-retreat.org

Please complete the form below. Complete one form per Retreatant.
The cost of the 5-Night Individual Retreat is $585.00 + FL tax and fees (Total is $639.63)
Private accommodations and all meals are included
Cancellation within 21 days of arrival results in forfeiture of $150.00 + tax and fees.

If you have any questions, please contact Denise Riley at:
riley@olph-retreat.org or (941) 486-0233 ext. 3004
The maximum number of form submissions has been reached. This form is currently not available.
- OLPH staff will review the registration form in strict confidence
- ----- RETREATANT INFORMATION -----
- Select the 5-Night Retreat Date REQUIRED
  Please select the retreat date you are requesting
  Please fill out this field.
- Retreatant's First Name REQUIRED Maximum 20 characters
  Please enter the first name of the Retreatant
  Please fill out this field. Please enter valid data.
- Retreatant's Last Name REQUIRED Maximum 35 characters
  Please enter the last name of the Retreatant.
  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.
- 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.
- Email REQUIRED
  Please enter the email address to use for OLPH correspondence
  Please fill out this field. Please enter an email address.
- Date of Birth REQUIRED
  Please enter your Date of Birth in MM/DD/YYYY format
  Please fill out this field. Please enter a date.
- 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 member of a religious community
  If you are a member of a religious community, please select the following
- 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 -----
- (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.
  Please note that OLPH is limited in its ability to accommodate special dietary needs.
- (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 -----
- (5a) Have you ever made a Directed Retreat? REQUIRED No Yes Please fill out this field.
- (5b) If yes, please identify most recent dates, type of retreat, and duration.
- (6a) Are you presently in Spiritual Direction? REQUIRED No Yes Please fill out this field.
- (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? REQUIRED Please fill out this field.
- (8) What desires, hopes, fears or concerns do you have for this retreat? REQUIRED Please fill out this field.
- ROOM AND PAYMENT INFORMATION
- Amount: REQUIRED
  Make your selection and press the Proceed to Payment button to complete your payment.
  Please fill out this field.
- Registration is not complete until you
  Proceed to Payment
Total:

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5-Night Retreat Registration

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