Shepherd's Heart Registration

Passport Information

Name as in Passport *

First

Middle

Last

Layout

Passport No *

Date of Birth *

Expiration *

Contact Information

Email *

Layout

Cell Phone *

Home Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact

Emergency Contact *

First

Last

Phone *

Accomodation

I have a Roommate *

Yes
No, please find me one ( In case we cannot find you a roommate you will be forced to a single room and be charged a single supplement of U$2,100 )
I want a single room ( I accept to be charge a single supplement of US$2,100 )

Roommate Name

First

Last

Bedding

Payment

I want to pay via *

Credit Card
Cheque

Cheque

Non-refundable Deposit $500 per person, make checks payable to Shepherd’s Heart Ministry – – – -Mail checks to: Shepherd’s Heart Ministry PO Box 4808 Parker, CO 80134 Deposit Deadline: November 30, 2023

Credit Card

Non-refundable Deposit $500 per person ——For credit card payments, please call 303-884-8030 (cc payments will be an additional 3% fee)—–

GDPR Agreement *

I consent to having this website store my submitted information so they can respond to my inquiry.

Shepherd’s Heart Registration

Passport Information

Contact Information

Emergency Contact

Accomodation

Payment

Cheque

Credit Card

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