5 Days of Healing - December 2025

Please complete the form below to submit your registration for the upcoming 5 Days of Healing seminar.

Your registration will not be complete until the $100 deposit is received by our office, either by cheque, money order, cash payment, or e-transfer to admin@jacobswellministries.ca. The remaining balance of $600 of the registration fee may be paid in cash or by cheque at check-in.

We serve a lot of fruits and fresh vegetables at each meal. Please contact us if you have any special dietary requirements.

The facility is nut-free.

5 Days of Healing Registration

First Name *

Last Name *

Birth Date *

Street Address *

City *

Postal Code *

Country *

Province/State *

Email Address *

Phone *

Emergency Contact 1 *

Emergency Contact 2

Food Allergies *

Yes No

If you selected "Yes", please list the detail of any serious food allergies. Please note: We serve a lot of fruits and fresh vegetables at each meal. If you have a food "preference" and are concerned that those preferences won't be met, you may bring food items. There is a small amount of fridge space for extras. The facility is nut-free.

Food Allergies detail

Health Concerns *

Yes No

If you selected "Yes", please list the health concerns in detail

Health Concerns details

Current critical issues *

Yes No

Are there any current critical issues occurring in your life that we should be aware of? If "Yes", please provide details below.

Current critical issues details

Have you asked Jesus to be Lord of your life? *

Yes No

Confidentiality confirmation *

Yes No

Select yes to confirm that you agree to keep confidential anything shared by participants during the seminar.

Remember, your registration will not be complete until our office receives the $100 deposit.