Faces of Christ Registration

Faces of Christ Registration
Group/Event Name
Today's Date

Month Day Year
Date
Name *

First Name Last Name
Name you go by *
Please enter how you would like your name spelled on your name tag
Gender *

Male Female
Date of birth *

Month Day Year
Marital Status *

Single Married Divorced Widowed
E-mail *
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Name of Spouse

First Name Last Name
Names of any children (and ages) *
Dietary (allergic) restrictions? *

Gluten Free Dairy Free Nut Free Vegetarian Diabetic Vegan Soy Free Corn Free Other No allergies
Describe your allergies on a scale of 1-5 as a mild sensitivity (level 1) to anaphylactic shock (level 5) Enter 0 for a preference (not an allergy)
Any mobility restrictions? *

Yes No Other
I want to attend this retreat because: *
Email
example@example.com
We would like to ask some of your believing friends to be praying for you during the weekend. Please list:
Nearest Christian Relative *

First Name Last Name
Phone Number *

Area Code Phone Number
Closest "in town" friend *

First Name Last Name
Phone Number *

Area Code Phone Number
This retreat was recommended to me by *

First Name Last Name
Phone Number *

Area Code Phone Number
In case of emergency please call *

First Name Last Name
Phone Number *

Area Code Phone Number
The registration fee for this retreat is $240.00.

Limited financial assistance is available. To be considered, a letter describing your need should be included with a $50 non-refundable deposit.
Please select which retreat you would like to register for:
Which retreat are you registering for? *

Women's February 2-5, 2023 retreat Men's February 9-12, 2023 retreat Women's July 20-23, 2023 retreat (FULL) Women's Oct 6-9, 2022 retreat (Join Waitlist) Men's Oct 13-16, 2022 retreat
What are you paying today? (If on waitlist, just pay deposit) *

Deposit only ($50.00) Full registration amount ($240.00)
Do you need financial assistance?

Yes No, I will be paying the balance upon arrival.
Limited Financial Assistance Available. To be considered, a letter describing your need should be included with a $50 (non-refundable) deposit. You may upload your letter here.
If you have trouble uploading a file, please email your letter to Joe@thepotterswheel.org or mail it to
PO Box 204
Fisherville, KY 40023. (please note, mailing is not the preferred method)

We do need your letter to process your financial assistance request.
Number
Calculation
Total paying today: *

prev next ( X )
USD Faces of Christ (If on waitlist just pay deposit)
Retreat will be held at
815 Country Lake Rd, Underwood, IN 47177
- No alcoholic beverages/tobacco products/drugs are allowed anywhere or anytime on the premises. Drug use includes any injected, ingested or inhaled substance that is deemed harmful and intended to induce a “high.” Country Lake Christian Retreat Center is a non-smoking environment and we ask our guests to use the designated smoking areas, which are the north and south parking lots.
- No guns/knives/weapons of any kind are permitted anywhere or anytime on the premises. If brought to the facility, leaders will be required to lock them in their trunks or secure them in the director’s office.
- Fireworks of any kind are not permitted without prior permission.
- Pets and other animals are not permitted.
I understand and agree to follow the rules above.
Your name typed is your electronic signature agreeing to the above restrictions.
Should be Empty:

Faces of Christ Registration

We would like to ask some of your believing friends to be praying for you during the weekend. Please list: