Name       M or F    T Shirt Size

Address City ST       Zip

Email address          Phone # DOB  

By Submitting this application I agree that I am committing to attend the Antioch retreat. I understand that application will only hold me a spot and allow for a cabin assignment and assist in the planning of the retreat with regards to food, lodging, chaperones and all other necessary items.

I acknowledge that I will submit the Parental consent form (if under 18) and any balance due* prior to attending the retreat or upon arrival at the retreat. I understand that I will not be able to stay on the retreat without the signed form.

Question/comment/request for information, please list name of person inviting you: 

Have you attended an Antioch Retreat before?  Yes   No   How many?

How would you like to be contacted?      

Someone will contact you in the very near future, Thanks and God Bless!

* Confidential Scholarship and financial aid available where applicable, no one denied any opportunity for financial reasons!