IDR Application Form for Session IV (Aug 9 - 18, 2023) To register, please complete this form and submit with the required non-refundable, non-transferable deposit. Required information marked with *Your TitleMr.Mrs.Ms.Fr.Sr.Dr.Name* First Last Suffix: Age: Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone:* Phone Type* Home Mobile Business Email:* Emergency Contact’s (EC) Full Name* Emergency Contact’s (EC) Phone Number* EC’s Relationship to the Retreatant* Occupation/Ministry: Religious Affiliation: Choose Dates from August 9 - 18, 2023There is a four-day minimum required. (Minimum of 4 complete days = 96 consecutive hours)Date of Arrival* Choose date from August 9 through August 14Time of Arrival* If your arrival date is the first day of the Session (i.e. August 9), your arrival time should not be earlier than 5:00 PM.Date of Departure* Choose date from August 13 through August 18Time of Departure* If your departure date is the last day of the Session (i.e. August 18), your departure time should not be later than 10 AM. Preference for director: No preference Laywoman Sister Priest Do you or have you had a Spiritual Director? If current, how long have you been in direction? If past, how long has it been since you have received spiritual direction?Special needs: First floor room Diabetic Vegetarian Have you made a directed retreat before?YesNoIs this your first retreat?YesNoIf No, where have you made a retreat and when was it? Are you confident and comfortable with a totally silent retreat? What are you hoping for in this retreat? (e.g., quiet time with God, direction in prayer, making important decisions, etc.)Additional Comments:Payment Method:* Credit Card eCheck Credit Card American ExpressDiscoverMasterCardVisaJCBMaestroSupported Credit Cards: American Express, Discover, MasterCard, Visa, JCB, Maestro Card Number Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Expiration Date Security Code Cardholder Name eCheck Name on Account Bank Name Routing Number Account Number CheckingSavingsAccount Type Nonrefundable Deposit:* $80 - Summer Session IV The application fee is the cost of one night’s stay ($80 or $85); this is nonrefundable and nontransferable but applicable to the cost of the retreat. The cost is: for Summer Sessions (June, July and August): $80 per day, or outside of the Summer sessions: $85 per day.