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Marymount Hermitage

2150 Hermitage Lane Mesa, ID 83643-5005
Phone: (208) 256-4354 (Message only)

APPLICANTS for solitary retreats of 2-7 days are kindly asked to complete this form. The information will be kept strictly confidential. Please sign your name under the photograph. Thank you very much.

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Name:	ATTACH RECENT PHOTO HERE
Address:
City, ST Zip:
Phone:
Email:
Circle preferred title: Rev. Fr. Bro. Mr. Sister Mrs. Miss Ms. Dr. Other:
Date of birth (mm/dd/yy):
Religion:	Occupation:
Parish (if applicable):	Employer:

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MEN and WOMEN RELIGIOUS or MEMBERS of a SECULAR INSTITUTE:

TITLE of CONGREGATION:
COMMUNITY INITIALS:
SUPERIOR’S NAME:
Type of Superior (Circle one):	Local, Provincial, Superior General
Address:
City, ST Zip:
Phone:

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How did you first hear of Marymount Hermitage?

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Why do you want to spend time in solitude here?

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Describe your present state of health:

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Mention any health factors which could possibly affect you while at Marymount Hermitage in solitude (e.g.) handicap, illness, recent surgery, allergies, medication, recent trauma, major life change, death of a loved one, etc.:

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CONTACT PERSON: In the unlikely event of a medical or other emergency, please give the name, address and phone of someone whom we may contact in your regard. You may give more than one contact person (list additional on reverse side). Also give a general description of your relationship to this person (e.g.) spouse, friend, son, religious superior:

Name:

Address:

City, ST Zip:

Phone:

Relationship:

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GUIDELINES:		Yes	No
	Do You smoke?
	Do you intend to bring a tape or cd recorder/player?
	Do you intend to request informal spiritual sharing with one of the Hermit Sisters?

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DIET: The community at Marymount Hermitage lives on a balanced diet of bread, beans, grains, vegetables fruit and dairy products. Fish is also available.		Yes	No
	Are you able and willing to cook your own meals in your hermitage?
	Will you be able to use the staples as described above?
	Are you requesting extra food supplies such as meat or provisions for a special diet? If yes please list items below or on back.

For extra food or special diet requests there is an additional fee of $50.00 payable with the deposit for purchases listed above. If the bill is significantly more, we will advise you of the additional cost and this will be payable with the retreat fee at the end of your stay at Marymount Hermitage.

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RESERVATION: Please specify Primary and alternative Dates		Starting	Ending
	Primary Dates Requested (mm/dd/yy)
	Alternative Dates Requested (mm/dd/yy)

COST: $37.45/day* x Number of days = Estimated cost of _________________________

Please make checks payable to Marymount Hermitage. The deposit is deducted from the total.

*(This fee includes $35.00/day for Marymount and $2.45 for applicable Idaho taxes.)

DEPOSIT POLICY: A non-refundable deposit of $30 must accompany this completed application form and the special diet fee, above, if applicable.

1. Your entire deposit will be returned to you within 30 days if we are unable to honor your request for the use of a hermitage.

2. If your application is accepted and you must defer the time of your retreat, your deposit will be held for one year from the time of the original reservation date.

3. If your application is accepted and you cancel your reservation, your deposit will not be refunded.

TRANSPORTATION: Please complete the information sheet (which can be printed off the internet) when your retreat reservation is confirmed in writing and your travel plans have been completed.

Please send this application form with your deposit to: Sister Mary Beverly, HSM at the address listed on the top of this form.

Thank you sincerely and God Bless you.