Recovering Couples Workshop Registration Form

Registration Form

“Recovering Our Connection”

Recovering Couples Workshop

    Workshop Dates:

    Name:

    Street Address:

    City:

    State:

    Zip Code:

    Daytime Phone:

    Evening Phone:

    Cell Phone:

    Your Email Address:

    Status:

    Best Number To Call:

    Name to be used for name tag:

    Partner's Name:

    Partner's Address:

    Partner's City:

    State:

    Zip Code:

    Partner's Daytime Phone:

    Partner's Evening Phone:

    Partner's Cell Phone:

    Partner's Email Address:

    Partner's Best Number To Call:

    Name to be used for name tag:

    Method of Payment:

    Credit Card No.:

    Expiration Date:

    How did you hear of us?:

    Referred by:

    Cost & Confirmation:
    $375 deposit is due with this registration to guarantee your space.  The $375 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 $375 within five (5) business day of receipt of this registration.  The remaining $375 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.