Journey to Healing Retreat

Journey to Healing Retreat Registration Form

Date:

Cost is $175.00 per person

Participant Information

Title:

Name:

Address:

City/Province:	State:	Zip:	Country: (if other than US)

Home Phone:	Work Phone:	Cell Phone:

Email:

Name of Church:

Denomination:

Payment Information

Form of payment:
Personal Check
Ministry or Parish Check - Please earmark date and name of attendee(s)
Money Order
Credit Card (we accept Visa, MasterCard, Discover and American Express)

Please indicate total amount of payment:

Credit Card Number:	Exp. Date: (month, year)

CCV Code:

What is a CCV Code?
On a Visa, MasterCard or Discover, please turn your card over and look in the signature strip. You will find (either the entire 16-digit string of your card number, OR just the last 4 digits), followed by a space, followed by a 3-digit number. That 3-digit number is your CVV2 number.

On American Express Cards, the CVV2 number is a 4-digit number that appears above the end of your card number.