Registration Form

The Center for Relationship

Training and Recovery

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Michael H. Borash, LPC, P.C. and Associates

Registration Form

"Getting the Love You Want"

Weekend Workshop for Couples

Workshop Dates:

Name:

Street Address:

City:

State:

Zip Code:

Daytime Phone:

Your email address

Evening Phone:

Cell Phone:

Status:

Best Number to Call

Partner's Name

Partner's Address

Partner's City

State

Zip Code:

Partner's Email

Daytime Phone

Evening Phone

Cell Phone

Best Number to Call:

Method of Payment

Credit Card No.:

Expiration Date:

How did you hear of us?

Referred by:

Name to be used for name tag:

Cost & Confirmation:

$325 deposit is due with this registration to guarantee your space. The $325 balance is due (and will be charged) one week prior to the workshop.

Payment by Check:

If you are paying by check: In order to guarantee your space we must receive your check in the amount of $325 within five (5) business day of receipt of this registration. The remaining $325 is due one week prior to the workshop. Complete this form, print and mail with checks payable to: Michael Borash. Click here for mailing address.