Interest in Registering for Rachel's Vineyard Retreat Form

- OLFF

Interest in Registering for the Rachel's Vineyard Retreat
I would like to participate in the April 25-27, 2025 Rachel's Vineyard Retreat weekend in Midcoast Maine.
Note: All info submitted is kept confidential
Contact Information

* All info submitted in this and subsequent sections will be kept confidential by the Project Rachel Team.
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- First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
- Mailing Address
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Best Phone Number to reach you REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- What phone is attached to the phone number above Home Work Cell
- Best time to call you Please enter valid data.
- Is it ok to contact you by email? Yes No
- Email Please enter an email address.
- Information for Accompaniment
  We ask for this information so we can better accompany you during the retreat.
- What best describes your abortion experience(s)? (Check all that apply) I had an abortion I am the father of an aborted child I paid for someone else to have an abortion I convinced someone to get an abortion I am a relative (i.e. grandmother, grandfather, aunt, uncle, cousin) of someone whose had an abortion I acted as an abortion provider Other (please specify in question below)
- Please specify if you checked off "other" in the previous question
- Approximate Date(s) of abortion experience(s): REQUIRED Please fill out this field.
- Approximate Date(s) of miscarriage(s) (if applicable):
- Have you ever discussed your abortion experience(s) with a counselor/therapist? Yes No
- When, if at all, have you used drugs or alcohol to numb the pain of your abortion experience? Currently In the past I have not used drugs or alcohol to numb the pain
- Are you currently being treated for any medical or psychiatric condition(s)? REQUIRED Yes No Please fill out this field.
- Please tell us about any medical/psychiatric conditions you are being treated for. REQUIRED Please fill out this field.
- Are you taking any prescribed medications? REQUIRED Yes No Please fill out this field.
- If yes, please list the names and purposes below: REQUIRED Please fill out this field.
- Please briefly describe your religious background or current preference(s): Please enter valid data.
- Are you comfortable in a setting where we use the Bible? Yes No Unsure
- What if any, dietary or accessibility concerns do you have for the retreat facilities or meals Please enter valid data.
- Your Hopes and Concerns
- How did you hear about the retreat? Please enter valid data.
- What do you hope the weekend will do for you? REQUIRED Please fill out this field.
- Do you have any questions or fears you would like to talk about before coming to the retreat. If so, please explain.
- What else would you like the team to know about you or your experience?
- In Case of Emergency
- Emergency Contact Name REQUIRED Please fill out this field. Please enter valid data.
- Emergency Contact Relation to You Please enter valid data.
- Emergency Contact Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Rachel's Vineyard Retreat Weekend 2025
  Participant Agreement
- I will maintain absolutely confidential the names of all retreat participants and the retreat location, as well as the content of what is shared during our sessions together Yes No
- I understand that the retreat time together starts at 3:00pm on Friday and ends by 1:00pm on Sunday. I commit to the entire retreat. If there is a pressing need for me to leave early, I will discuss it with a Retreat Team member before leaving Yes No
- I understand that the chief focus of the retreat is spiritual and emotional healing and does not constitute clinical counseling Yes No
- Retreat Cost
  The suggested registration fee is $150/retreatant. The actual cost to the Diocese to host a retreat weekend is $400/person. While we do not want the registration fee to prevent anyone from attending the retreat, we do ask that retreatants pay what they can to help offset expenses.
  
  Please prayerfully consider what you can afford to contribute towards retreat expenses and enter that amount below. After you and the Project Rachel coordinator discern that this retreat experience is a good fit for you at this time, your payment will be due at least 1 week before the retreat. Payment may be made by check, ACH payment, credit/debit card, or money order payable to "Diocese of Portland" and can be mailed to:
  
  Roman Catholic Diocese of Portland--OLFF
  Attn: Project Rachel
  510 Ocean Ave
  Portland, ME 04103
  
  Any amount over $400 will be noted as a donation to assist others in attending.
- How much will you pay towards the cost of the retreat weekend REQUIRED $ Please fill out this field. Please enter a positive decimal.
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Interest in Registering for Rachel's Vineyard Retreat Form

Interest in Registering for the Rachel's Vineyard Retreat

Information for Accompaniment

Your Hopes and Concerns

In Case of Emergency

Rachel's Vineyard Retreat Weekend 2025

Retreat Cost