We are happy you have chosen to attend a Via de Cristo weekend at Rivers Edge.
  
  Please choose what upcoming weekend are you applying for?

Men's Spring 2009 held at the LaSalle Center in Eureka, MO (April 30 - May 3, 2009)
Women's Fall 2009 held at the LaSalle Center in Eureka, MO (Oct. 29 - Nov. 1, 2009) 

  Applicant Information:

First Name
Last Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Date of Birth
Marital Status:	Select One Married Single Divorced Widow
Work Phone
Home Phone
E-Mail Address

  Family Information:

Spouse Full Name
Spouse Work Phone
Number of Children:	Select One 0 1 2 3 4 5 6 >6

  Home Church Information:

Pastor's Name
Home Church Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code

  Has the Via de Cristo weekend been explained to you?

Yes No

  Has Group Reunion been explained to you?

Yes No

  Do you have any special dietary requirements?

Yes No

  If yes, please explain:

  Do you require medications at a specific time each day?

Yes No

  If yes, please explain:

  Do you have health/physical restrictions requiring special equipment or facilities?

Yes No

  If yes, please explain:

  Do you have any special sleeping needs?

Yes No

  If yes, please explain:

  Enter today's date:

-- mm/dd/yyyy

Comments:

  Note: The cost of the weekend is $150.00.  This includes food and beds.  It is payable with
              your registration.  
  Make checks payable to:  Rivers Edge Via de Cristo
  Mail checks to:   Ellie Newton Rivero- 127-D Park Charles Blvd. South, St. Peters, MO 63376
  Questions - wayne@riversedgevdc.org

  The deadline to receive your application is 10 days prior to the start of the weekend.