Online Registration – Living Waters Ministry

Have you attended a retreat at Living Waters before? *

Yes

No

How did you hear about the retreats at Living Waters? * How did you hear about the retreats at Living Waters?

Retreat/Class you wish to attend: *

Retreat/Class you are registering for:

Title *

First Name *

Last Name *

Address *

Address

City

State/Province

Zip/Postal

Country

Phone *

Email *

Date of Birth (MM/DD/YY) *

Age group *

If you are age 13-17, what is your parent/guardian's name?

Marital Status *

Emergency Contact *

Emergency Contact's Phone Number *

More About You (On-Site Retreats Only):

Please attach a recent photo of yourself for us to connect a face with the name as we are praying for you.

Maximum upload size: 314.57MB

Do you have food allergies? *

Yes

No

N/A

If yes, please describe your food allergies:

Do you have a medical issue that would prevent you from climbing stairs?

Yes

No

For us to better minister to you, please answer the following questions (On-Site Retreats Only):

Did your pastor refer you? *

Yes

No

If your pastor referred you, what specific situation are you needing to work on? If not, type "n/a" below: *

Have you ever considered any type of self harm? *

Yes

No

N/A

Do you or have you ever had addiction(s)? *

Yes

No

N/A

If you answered "yes" to the above question, explain all addiction problems. Please note if they are past or current problems. If you answered "no" above, type "n/a" below: *

Are you presently receiving counseling? *

Yes

No

N/A

Please describe your reason for attending this retreat (reply N/A if not attending an on-site retreat): *

Please describe your background in reference to your relationship with God (reply N/A if not attending an on-site retreat): *

Have you had a major loss in the past year? *

Yes

No

N/A

If yes, please let us know in short detail about the loss:

Also, would you like to receive our monthly newsletter?

Yes

No

The Exodus Mission Retreat Questions:

The following questions will help us to be able to minister to you more effectively. Our retreat is Faith Based so our program is called ministry. Please note, the answers to the questions in this section will not affect you coming to a retreat. Do you have any previous experience in a Faith Based program? If yes, please explain. If no, simply type "no" and type "n/a" if not applicable to your registration. *

Have you served in the Military? *

Yes

No

N/A

When did you serve in the Military and which Branch? Type "n/a" if not applicable to your registration. *

Have you been diagnosed with PTSD? *

Yes

No

N/A

Are you in therapy now? *

Yes

No

N/A

If yes, please explain the extent of your treatment. If no or n/a, simply type "n/a". *

Are you interested in learning about our follow-up after the retreat? *

Yes

No

N/A

Online Class Questions:

Reason for Registering for the 10-week online Phase I HTH Class? *

Healing

Preparation for Advanced Training Certification

OtherOther

N/A

Church Affiliation (reply N/A if not registering for online classes)? *

Have you paid the $150 enrollment donation?

Yes

Not Yet

N/A