Rivers Edge Via de Cristo 
Pilgrim Application

We are pleased that you have chosen to attend a Via de Cristo weekend at Rivers Edge!

Applicant Information
  * Indicates a required field
First Name *
Last Name *
Street Address  
Address (cont.)  
City  
State/Province  
Zip/Postal Code  
Date of Birth  
Marital Status  
Gender *
Home Phone  
Cell Phone  
Work Phone  
E-Mail Address *
Family Information
Spouse Full Name  
Spouse Work Phone  
# of Children  
Home Church Information
Pastor's Name  
Home Church  
Street Address  
Address (cont.)  
City  
State/Province
Zip/Postal Code  
Has the Via de Cristo weekend been explained to you? *
Has Group Reunion been explained to you? *
Do you have any special dietary requirements? *
If yes, please explain:
Do you require medications at a specific time each day? *
If yes, please explain:
Do you have health/physical restrictions requiring special equipment or facilities? *
If yes, please explain:
Do you have any special sleeping needs? *
If yes, please explain:
Comments    
Note:  The cost of the weekend is $150.00.  This includes food and beds.  It is payable with your registration.
  
  Make checks payable to: 
Rivers Edge Via de Cristo

  Mail checks to: 
Diane Maertens
6 Paulette Drive
 Belleville, IL 62226

  The deadline to receive your application is 10 days prior to the start of the weekend.

River's Edge Via de Cristo
Revised: October 19, 2015