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Rebuilding Registration Form

We treat your personal information as confidential and will release it only as might be necessary to serve you, and only to duly recognized representatives of the Diocese of St. Augustine, St. Vincent's Medical Center, or the priest(s) and parish(es) you designate below. 

Click here for more information on our Privacy Policy.

This a structured eleven-week educational seminar for separated, divorced and widowed persons.  It is a closed group which studies and prays together in confidentiality with compassionate support. The sessions are facilitated by experienced and professional leaders.  The classes are held at the Catholic Center annually, are open to all denominations and require pre-registration.  For more information contact the Diocesan Center for Family Life at (904) 308-7474.

Our next session will begin on Thursday evening, March 11, 2010 at      7 PM.  Cost is $40.00 for the program.  Classes are held at the Catholic Center, 11625 Old St. Augustine Rd., Jacksonville.  Classes will continue each Thursday evening through May 13, 2010.

General Information:

First Name
Last Name
Address
City, State, Zip
Home Phone
Work Phone
Cell Phone
E-mail
Date of Birth


Marital Status:
 

 Widowed

Divorced

Separated

Date of Separation/Divorce/Loss

How did you hear about this program?


What do you expect to gain from this program?



Are you interested in learning more about additional programs?

 Yes

No    

Do you have an annulment?

 Yes

No    

Can we provide you with annulment information?

 Yes

No    

Select a Payment Method:

VISA   MasterCard   Check    Other

If paying by credit card, please complete requested information on the next page.

Comments:

If paying by credit card, confirmation will be sent by e-mail (if provided) or by mail.
If paying by check, confirmation will be sent by e-mail (if provided) or by mail ONLY when your check has been received.  Checks should be made out to Diocesan Center for Family Life.

Any questions, please contact (904) 308-7474



    

"The Lord has turned all our sunsets into sunrise."

St. Clement of Alexandria

  
 2577 Park Street    
   Jacksonville, FL 32204    
   Phone (904) 308-7474    
Copyright © 2007 Diocesan Center for Family Life                                                                                             Fax (904) 308-4087    

                                            Diocese of St. Augustine St. Vincent's Medical Center