Prov 5 Spring Retreat Registration 
Name *
E-mail Address: *
E-mail Address
Mailing (Postal) Address *
Phone Number *
Chaplain or Student Minister
Gender *
Room Choice (Quad $105 Double $160 Single $180) *
Roommate Requests
Let us know if you are interested in serving as (Chalice Bearer, Reader, Leader)
T-Shirt Size (S,M,L,XL,XXL) *
Emergency Contact Name *
Emergency Contact Phone *
Please Sign by Typing your Name *
* RequiredCreate Email Forms
Feel Free to Print and then please send $60 dollar deposit to:
 
The Rev. Collins Asonye
Grace Episcopal Church
308 2nd St, Defiance, OH 43512
Make checks payable to “Trustees of Province V Midwest”
with a note to “Campus Ministry”
 
Any Question feel free to Contact The Rev. Collins Asonye at 03Prince@earthlink.net
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