RESERVATION FORM—”Men's Palm Sunday Weekend Retreat”— April 15-17, 2011 $155 per person (For Credit Card payment; name as it appears on the card and statement address)

Name                                                                            Last Name                                                                                                   E-Mail Address  

Address                                                                                                                City                                                                   State                                                            Zip

(         )  ________________      (         )_________________

Daytime Phone                                          Evening Phone

Parish or Affiliation______________________________            Signature (for Credit Card payment only) ______________________________________________

Payment Method:  Check _____  Cash_____ DISCOVER/VISA /MasterCard_______________________________________________            _________________

                                                                                                (Circle One)                          Credit Card Number                                                Exp. Date

In order for us to make your stay as comfortable as possible, please make us aware of any special needs you may have:

Physical _______________________________Dietary ________________________Spiritual _______________________________

Please complete reservation form and mail, along with your deposit to: Loyola Retreat House, 700 Killinger Rd. Clinton, OH 44216-9653.  For more information call (330) 896-2315.  Thank You!