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Ultreya
4th Day Renewal Weekend
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Cum Christo Application
First Name
Name on Nametag
Address
City
State
Occupation
Last Name
Email
Phone Number
Zip Code
Birthdate
Gender
Female
Male
Spouse Name (if applicable)
Religous Affiliation
Baptized
Yes
No
Pastor/Clergy Name
Pastor/Clergy Endorsement
Yes
Not Yet
Do you require physical assistance?
Yes
No
Do you use CPAP?
Yes
No
Primary Care Provider
Preferred Hospital
St. Vincent Healthcare
Billings Clinic
Sponsors Name
Is Spouse attending the weekend?
Yes
No
Name of Church Attending
Enter any food allergies or medical diet requirements?
Do you take medications that are time sensitive?
Yes
No
Emergency Contact Name
Emergency Contact Phone Number
Do you have a sponsor?
Yes
No
Sponsors Phone Number
Sponsors Email Address (if known)
Has your sponsor explained the Cum Christo Weekend to you?
Yes
No
May we print your name as a participant?
Yes
No
Message
Submit
Thanks for submitting!
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