* Couple's Last Name:
* Husband's name:
* Wife's Name:
* Street Address:
* City, State, Zip:
* Contact Phone Number:
* Name and Number of an Emergency Contact:
* Neuse Baptist Church includes pictures regularly on our Church Website and Facebook Page. Please choose :
Yes, you may use registrant's likeness on Church media
No, please do not use registrant's likeness on Church media
* By completing and submitting this form, you are registering for The Couples' Retreat. Please be aware that by registering, you are authorizing a hotel registration to be made in your name.
To accept, please check the box, complete the authentication, and click SEND.
After you answer the authentication question below and submit your form, you will receive a message that contains a link to our church's Online Giving page. You may pay your registration online using our secure site or you may pay your fee at Church. If you pay at church, please use an offering envelope and designate your gift as "Couples' Retreat". Please designate below how you would like to pay for your Retreat Registration Fee
* Form of Payment:
I will pay Online using Online Giving
I will Pay at the Church
* 3 + 5 =
Enter the correct answer to the math question.
Please click the Send button only once.