This form should be completed and mailed to the above address.

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CHA RETREAT REGISTRATION FORM

Due to the serious nature of entering into a solitary retreat in a Sonoran desert wildland setting, the following information is required before we can grant final acceptance.

Name___________________________________________________________________
Address_________________________________________________________________
Phone number____________________________________________________________
E-mail address____________________________________________________________

Emergency contact: Name_______________________ Phone number_______________

Briefly state why you are requesting a solitary retreat_____________________________
________________________________________________________________________
________________________________________________________________________

Describe nature and duration of past solitary experiences (if any)____________________
________________________________________________________________________

_______________________________________________________________________

Proposed dates of retreat____________________________________________________

Note: Because a solitary retreat with CHA requires a substantial commitment of time, effort and scheduling on the part of staff and volunteers, we ask that you carefully consider your schedule before making a reservation and that you make every effort to keep your retreat commitment. If you are unable to do so please notify CHA as soon as possible.

I, ____________________(print name) have read the Introduction to Sojourners and the land Covenant and agree to abide by the Covenant while on retreat. To the best of my knowledge I have no physical or mental condition that would preclude my participation in a solitary retreat.

Signature _______________________________ Date_____________________