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Last Name*

Age*

Email*

Phone*

Home Church*

Home Church if outside the LA, Southern California, & Hawaii Diocese

Father of Confession*

Father of Confession Phone Number*

Visitors*

Day of Arrival*

Arrival Time*

Day of Depature*

Departure Time*

List Name, Age, Emergency Contact for each retreater*

I agree to the <a href='https://laconvent.org/rules-guidelines/' target='_blank'>convent retreat policies</a>.

I understand that I must contact the Convent at least one week in advance to confirm or cancel my retreat. يجب عليّ التواصل مع الدير قبل موعد خلوَتي بأسبوع على الأقل لتأكيد الحضور أو الاعتذار عن الحضور.

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