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