Cursillo Application

Please print

Mr.

Mrs.

Ms.

Dr.

Rev.

Name

On Name Tag

Email:

Street Address:

City

State

Zip Code

Home Phone

(        )

Are you confirmed Episcopalian?

Work Phone

(       )

Smoker

Non-Smoker

Birthday: Month

Day

Year

Occupation

Church/Parish

City of Parish

Sponsor Name:

Street Address:

City

State

Zip Code

Home Phone

(       )

Work Phone

(       )

Sponsor's Parish

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