AZ 5 Day Academy Registration Name* First Last Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* GenderAre you Clergy or Laity Clergy Laity What is your denomination?Registration Fee*Single Occupancy - $875Double Occupancy - $825Hold my spot with a $200 partial paymentThe fees will be $825 for double occupancy, received before August 1st; $875 for single occupancy, received before August 1st. After August 1st the rates go up to $925 (double) and $975 (single). If a $200 refundable partial payment is done please keep in mind that the remainder is due by August 1, 2019.If selection is Double Room Occupancy please state name of roommate.Scholarship Form RequestDSC clergy may apply for scholarship assistance with the Conference Board of Ordained Ministry. Some scholarship funds are available for laypersons from the Desert Southwest Conference. For information, please contact Jerry Haas, retreat leader at *protected email*. Yes Special Diet RequestNoneVegetarianVeganGluten SensitivityOther - Fill in belowPlease let us know if you have any dietary issues.If other please name other diet requestTotal to Pay Now $0.00 Credit Card Card Details Cardholder Name PhoneThis field is for validation purposes and should be left unchanged.