Emmanuel College

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InterMission Retreat

Take48 Intermission Retreat

Personal Information

First Name: Last Name: E-mail: Phone #: Address: City: State: Zip: College: Religious Tradition:

Class of:2011201220132014

Emergency Contact Information

Contact Name: Phone #:

Additional Information

Are you taking any medication at the present time?
NoYes

If YES, please designate what type of medicine and for what reason:

Do you have any special diet needs or an allergy to certain foods?NoYes

If YES, please explain:

Are there any other needs the retreat staff should know about?NoYes

If YES, please explain:

What is the time of your last class on Friday?:

How did you hear about this retreat?

Retreat Fee = $25.00. Payment due by October 12, 2010.
Please bring cash or check payment to Campus Ministry (Admin 003). If paying by check, please make it payable to: Emmanuel College.
Fee is refundable once you have attended the retreat, but is non-refundable with a cancellation 48-hours or less before the departure date.

The information on this registration will remain confidential and will be used only in preparation for the retreat. If you have any questions or would like to discuss scholarship assistance, please contact Jen Reis, 617-735-9777.

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InterMission Retreat