Reservation Form

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Last Name
First Name
Age
Name of the program you wish to register for:
Arrival Date
Departure Date
If you are a vowed religious, your congregational initials
Are you a member of the Philadelphia SSJ Associates in Mission?	Yes No
Street Address
City
State
Zip
Email
Home Phone
Work Phone
Emergency Contact Name (1)
Contact 1 Phone
Emergency Contact Name (2)
Contact 2 Phone
Health considerations that affect your room assignment
Room Preference
*Do you need a room on the first floor?	Yes No
*Can you have a room above the second floor? Please do not respond yes unless you are truly able to climb the extra flight of stairs without physical difficulty. Please note that we have almost 50 third floor rooms and cannot accept all reservations without using them.	Yes No
For a directed retreat, what is your preference for a director? Name of preferred director(s), in order of preference:
If you have no preference for a director for your directed retreat, do you prefer a man or a woman?	Man Woman Either
If we cannot honor these preferences, may we assign you someone else?	Yes No
*Reservations will be held for ONLY ten (10) days pending receipt of deposit.
* fields are required