Cursillo Application

Please print

Mr. Mrs. Ms. Dr. Rev.

Name _____________________________________________________________________ 

Name On Name Tag _______________________________________

Email: _____________________________________________________________________ 

Street Address: __________________________________________________________________

City _____________________________________________ State ___ Zip Code_____________ 

Home Phone_________________________ Are you confirmed Episcopalian/Anglican? ______

Cell Phone __________________________ Smoker? ______ Birthday: ____________________

Month Day Year

Occupation __________________________________________________________________ 

Church/Parish  __________________________________ City of Parish ___________________

Sponsor Name:  __________________________________________________

Street Address:  _________________________________________________________________

City _____________________________ State _____ Zip Code _______________ 

Home Phone ___________________________ Cell Phone _______________________________

Sponsor's Parish _______________________________________ City ______________________

Applicant's Signature _____________________________________________________________ 

Priest's Signature _________________________________________________________________

We can take Master Card, Discover and Visa. We need the following information: Amount paid, Card type, name on card, address with zipcode, card number, expiration date and signature.

Which weekend you wish to attend: ________________

Fee: $150.00 Mail application and deposit of $75.00 to:
Episcopal Center For Renewal
10290 Monroe Dr Ste 101
Dallas TX 75229-5718
FAX 214-351-3992

For Office Use Only

Fee Paid Cash/Check/Credit Card Date Received

Acceptance Letter Sponsor Letter