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.