REGISTRATION

36TH ANNUAL SPIRITUAL RETREAT
JANUARY 15-18, 2026
$285.00 REGISTRATION COST INCLUDES FOOD, LODGING, & ALL ACTIVITIES

EACH REGISTRATION FORM IS FOR ONE REGISTRATION.

IF REGISTERING FOR MULTIPLE PEOPLE, PLEASE FILL OUT AND SUBMIT ONE FORM FOR EACH REGISTRANT.

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NAME *

First

Last

AREA

tell us where you’re coming from!

EMAIL *

PHONE NUMBER *

GENDER *

• MALE
• FEMALE
• NON-BINARY
• OTHER

CLEAN DATE *

ARE YOU REQUESTING A SCHOLARSHIP? *

• YES
• NO

If YES– please do not forget to send your letter to RETREAT@PALMCOASTNA.ORG

*PLEASE NOTE: Cabin and/or Bed choice may be selected for you.*

DID YOU REVIEW THE AVAILABLE CABINS AND BEDS LINK AT THE TOP OF THIS PAGE? *

• YES
• NO

IF NO, PLEASE REVIEW BEFORE CONTINUING TO THE NEXT SELECTION TO ENSURE WHAT YOU ARE WANTING IS STILL AVAILABLE.

CABIN SELECTION *SELECT CABIN NAMEREQUESTING SCHOLARSHIPLODGE 1- WOMEN__________SurrenderPatienceFaithAcceptanceHopeCourageIntegrityWillingness__________LODGE 2-MEN__________Cabin Humility (Men)Humility (Men)Unity (Men)Open Mindedness (Men)Wisdom (Men)Serenity (Men)Service (Men)Honesty (Men)Gratitude (Men)__________RIVERSIDE DORM__________Compassion (Women)Unconditional Love (Gender Neutral/LGBTQ+ Inclusive)

TOP OR BOTTOM BUNK *

• TOP
• BOTTOM
• REQUESTING SCHOLARSHIP

BUNK NAME OR

DIET CHOICE *

• REGULAR
• GLUTEN FREE
• VEGETARIAN

WILLING TO BE OF SERVICE? *

• YES
• NO

WILLING TO:

• CHAIR A MEETING
• SHARE AT A MEETING

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