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Hold My Heart Couples Workshop Registration
Please fill out the following registration form to participate in the upcoming Hold My Heart Workshop! (1/3/15) I would strongly suggest that you sit together to fill out this form. All responses will be kept confidential.
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First and Last Name of both partners
Your answer
What is your email address?
Your answer
What is the best phone number to reach you?
Your answer
How long have you been together?
Your answer
What are your strengths as a couple?
Your answer
What are your weaknesses as a couple?
Your answer
What is the biggest challenge in your relationship?
Your answer
What is the greatest ONE thing about your relationship?
Your answer
What fears do you each have around your relationship?
Your answer
Do you have children? If so, how many? Ages? Living at home?
Your answer
Do you have any physical limitations that may prevent you from participating?
Sitting in a chair for more than an hour at a time, walking, etc...
Yes
No
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Do you have any dietary restrictions? If so, please let us know here.
Your answer
How will you be paying for the workshop? (Select all that apply)
Payments can be made via PayPal to
Roger@lifetrekpdx.com
.
Paying in full before 9/30/14 ($50 discount)
Paying in full after 10/1/14
Installment Payments - Paying a deposit of $100 before 9/20/14 ($25 discount)
Installment Payments - Paying a deposit of $100 after 10/1/14
Please contact me for other payment arrangements.
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