First Name * Last Name * Title Br. Dr. Sr. Fr. Deacon Pastor Ms. Mr. Address * Address 2 City * State/Prov. * Other/International Alabama Alaska Alberta Arizona Arkansas Australian Capital Territory British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New South Wales New York Newfoundland North Carolina North Dakota Northern Territory Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Queensland Rhode Island Saskatchewan South Australia South Carolina South Dakota Tasmania Tennessee Texas Utah Vermont Victoria Virginia Washington West Virginia Western Australia Wisconsin Wyoming Yukon Territory Zip/Postal * Country * United States Canada Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua And Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia And Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire (Ivory Coast) Croatia (Hrvatska) Cuba Cyprus Czech Republic Democratic Republic Of Congo (Zaire) Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France France, Metropolitan French Guinea French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard And McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar (Burma) Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Kitts And Nevis Saint Lucia Saint Vincent And The Grenadines San Marino Sao Tome And Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovak Republic Slovenia Solomon Islands Somalia South Africa South Georgia And South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard And Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad And Tobago Tunisia Turkey Turkmenistan Turks And Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City (Holy See) Venezuela Vietnam Virgin Islands (British) Virgin Islands (US) Wallis And Futuna Islands Western Sahara Western Samoa Yemen Zambia Zimbabwe Email * Phone * Denomination Birth Date
Gender Male Female Trans* Medical Issues Enter "none" if you have no issues Food Allergies Emergency Contact Info First Floor Bedroom required Most of our bedrooms are located on the second and third floors, accessible only by stairs. Is a second or third floor bedroom possible for you? How did you hear about us? A friend Internet Search Website Advertisement Other Special Diet Gluten free Pescatarian Vegetarian Vegan Severe allergy, including gluten (we may not be able to accommodate these needs and will follow up) Please note that we are not a peanut/nut-free facility. Many of our breads and other commercial foods we purchase may contain or may come into contact with common allergens, including wheat, peanuts, soy, tree nuts, milk, eggs, fish and shellfish. In addition, the manufacturers of the foods we purchase could change their formulations at any time without notice. Please also note the foods we prepare without gluten ingredients are not certified gluten free. Most of our baked goods and breakfast items contain eggs, dairy and wheat, unless specifically marked otherwise.
We are unable to accommodate food preferences while maintaining our commitment to sustainability and care for the environment. We are also unable to accommodate severe food allergies. There is refrigerator space available to accommodate all severe allergies and food preferences not listed above. Thank you for your understanding. Spiritual Ministry If applicable, please list any spiritual ministry. Occupation What is your current occupation? Attended SRC Retreat Spiritual Exercises Further information Other information that would be helpful for us to know as we seek to assign the right spiritual director for you. Introduction to silent retreat Directed retreat experience Reasons for making retreat What are your personal reasons for making this retreat? Spiritual Director Qualities What qualities would you like in a spiritual director? Specific Spiritual Director If you meet regularly with a spiritual director on this retreat and would like this person to accompany you on this retreat, please list their name here. Each retreat director meets with a limited number of retreatants. For this reason we cannot guarantee that the director you specify here is available for you. When your requested director is not available, we will assign you to another director who we see best fit. If you are not open to another director, you are still welcome to attend but please indicate "no director needed". Have you ever been in spiritual direction? If so, please comment on your experience. Highest Level of Education High School Undergraduate degree Masters Doctorate SRC Email newsletter Handmaid News Terms and Conditions * As part of the consideration for the use of the facilities of St. Raphaela Center at 616 Coopertown Rd, Haverford, PA 19041, and intending hereby to be legally bound, the undersigned organization and/or individuals (as indicated), hereby agree to indemnify, defend, and hold harmless St. Raphaela Center and the Handmaids of the Sacred Heart of Jesus and all of their members, officers, directors, employees, volunteers and agents from and against all claims, suits, actions, demands, charges, obligations, costs and expenses, or financial responsibility, including attorney’s fees and costs of suit, to which it or they may ever be threatened, exposed or found liable arising from or out of the use of the said facilities, or arising out of incident, accident, or injury occurring while the individual or group is utilizing St. Raphaela Center, including but not limited to actions regarding our health and safety guidelines in relation to COVID-19, or any of the acts or omissions of the undersigned or their agents, employees or members. This obligation of undersigned to hold harmless, defend and indemnify shall begin immediately upon notice of a claim and shall not require any actual loss to be suffered by the parties indemnified. 
