Candidate App - Online | Cursillo

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Street Address: REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Birth Date REQUIRED Please fill out this field. Please enter valid data.

Marital Status REQUIRED Single Married Widowed Divorced Separated Please fill out this field.

Male/Female REQUIRED Male Female Please fill out this field.

Spouse Name Please enter valid data.

Number of Children Please enter an integer (number).

Home/Cell Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Work Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Church Now Attending Please enter valid data.

Pastor Please enter valid data.

Employer & Occupation Please enter valid data.

Years of Formal Education Please enter valid data.

Email Address REQUIRED Please fill out this field. Please enter an email address.

Religious and Community Organizations in Which You Are Active:

Have you participated in any Cursillo activities: Monday night Mass, Ultreya, Day of Renewal, Rekindle programs? Yes No

Are you on special medication? Yes No

Are you on a special diet? Yes No

Do you have a health problem or physical handicap that might affect your attendance at a Cursillo? Yes No

Are you aware that there is no intercommunion? Yes No

Can you climb stairs? Yes No

State briefly why you wish to make a Cursillo weekend and what you expect from your retreat.

Payment Options 30.0 – Pre-Registration deposit 150.0 – Pay in Full

Peoria Cursillo Center