Emerge High School Retreat Registration Form if paying with check Student InformationName(Required) First Last Date of Birth:(Required) Gender:(Required) Dietary Needs/Allergies/Medical Restrictions: Parent/Guardian InformationName(Required) First Last Relationship to Student:(Required) Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Email(Required) Emerge Registration Fee - $75 Deposit - $50 Total Registration Fee - $75 Please make your check payable to the Diocese of Scranton and mail it to the Office for Parish Life, Attn: Shannon Kowalski, Diocesan Pastoral Center 330 Wyoming Avenue Scranton, PA 18503
