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 Application for the CREDO in recovery weekend

 

DATE OF THE WEEKEND_______________________________________________
 
I WAS INVITED BY_____________________________________________________


CANDIDATE---Please type or print clearly 

NAME: _____________________________________________________

NAME WANTED ON NAME TAG:_____________________________

ADDRESS:__________________________________________________

CITY:________________________STATE:______ZIP:_____________

 PHONE-home:_________________work:________________ 

EMAIL:___________________________________________________
 

Please explain any problems or detail any special needs you may have

SPECIAL DIET:____________________________________________________

PHYSICAL NEED:__________________________________________________

MEDICAL PROBLEM:______________________________________________

MEDICINES REQUIRED:____________________________________________

HOW OFTEN:_____________________________________________________ 

Suggested donation for the Weekend ranges from $75.00 to $110.00 - depending on facility used.

Note: ROUND TRIP DOOR-TO-DOOR TRANSPORTATION WILL BE PROVIDED. 

Please submit this application with a $20.00 deposit to Jim Hoffman, 619 2nd Avenue, West Cape May, NJ 08204.  Phone 609-884-8349.  Please make checks payable to CREDO. 

Please do not write below this line. 

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Deposit________________Date of Deposit:_________________________ Weekend Date:___________