Beginning Experience of Rochester, NY - Weekend Application 2020
at Notre Dame Retreat House in Canandaigua, NY
Name______________________________________________ Circle One: Male Female
City____________________________________ State______ Zip Code_________________
Phone_______________________________ Cell Phone___________________________
Date of Birth: ______/_______/________ Number of Years Married_________________
Separated Yes No How long?___________ Are you considering reconciliation? Yes No
Divorced Yes No How Long?__________ Widowed Yes No How Long?_________
Number of Children___________ Ages______________________
Religion _____________________ Parish or Church _____________________________________
The Beginning Experience Weekend is appealing to me because ___________________________
What do you hope to gain from the program? ___________________________________________
Heard about BE from_______________________________________________________________
Physical or dietary limitations we should be aware of?______________________________________
Are you currently in counseling? _______________________________________________________
Signature _______________________________________________ Today's Date _____________
Note: If you are in therapy, you must have permission of your therapist to participate on the Weekend.
Cost of the Weekend includes meals & lodging. Include a check for $75.00 as a deposit to reserve your spot.
Deposit is refundable when requested up to 7 days before the Weekend, balance due on or before the Weekend.
Weekend Cost: A private room is $245.00 for the weekend. A shared room is $200.00 for the weekend.
Checks should be made out to: Beginning Experience of Rochester
Mail to: Beginning Experience of Rochester ~ PO Box 92248 ~ Rochester, NY 14692
You will receive a confirmation of your application and deposit.
What to bring for your Weekend:
Notebook and pen Comb/hairbrush Slippers
Warm comfy clothes Hair dryer Flashlight
Toiletries Curling iron Coffee mug AND travel beverage container
Soap Snack to share
Shampoo Beverage to share