Women's Retreat Application
**Please note: All applications and fees must be received 14 days prior to the event to attend. No daycare is provided. All participants must be at least 18 years of age to attend.**

Women’s Retreat Application-(Please copy and paste this form into a document, print and mail off to: Destiny Ranch, PO Box 92, Alvord, IA 51230)
Cost: $75 per person per retreat. Please bring a salad, dessert or dish to share for our Friday evening potluck. All other meals are provided. Please feel free to bless the ladies at the retreat by bringing bars or snacks for the week-end.
We will begin registration for the retreat at 1 pm on Friday and start the retreat at 1:30pm. We will end the retreat around 1-2 pm on Sunday.  
April 27-29, 2012________
Sept. 28-30, 2012_________
Participant's Full Name: ___________________________________________________
DOB: ________________________________
Height: ______________________________Weight: _____________
Date of last tetnus shot: _________________
Street Address:_________________________________________ Apt# ___________
City: _______________________________ State: ______________________________
Zip: ________________________________Home Phone#: ( )_____________________
Cell Phone#: ( )_______________________Work Phone#: ( )________________
E-mail_________________________________________________________________
Employer/School: _______________________________________________________Church You Attend: ______________________________________________________
How did you hear about Destiny Youth Ranch?:
___________________________________________________________

PHOTO RELEASE:
I consent to and authorize the use and reproduction by Destiny Youth Ranch of any and all photographs and any other audio/visual materials taken of me for promotional material, educational activities, exhibitions, or for any other use for the benefit of the program.

Signature of Applicant:_____________________________________Date:____________

This retreat is for women 18 years of age and older.
______I have enclosed a check/cash for $______
______I have filled out the Application Form
______I have enclosed the Authorized for Emergency Medical Treatment Form
______I have enclosed the Release and Waiver Form
______I would like more info on available scholarships for the D.Y.R. Program
Please send forms and payment to: Destiny Youth Ranch, PO Box 92, Alvord, IA 51230