Beginning Experience of Rochester 2012 Weekend April 27-29, 2012
Name__________________________ Circle One: Male Female
Address__________________________________________________________________
City__________________________ State____ Zip Code___________
Phone_____________________ Cell Phone________________________
Email_________________________________
Circle Age: 20-25 26-30 31-34 35-39 40-45 46-50 51-55 56-60 61-65 66+
Separated Yes No How long?___________ Are you considering reconciliation? Yes No
Divorced Yes No How Long?__________
Widowed Yes No How Long?_________
Number of Years Married________________
Number of Children___________ Ages______________________
The Beginning Experience Weekend is appealing to me because
_____________________________________________________________________________
____________________________________________________________________________
Heard about BE from_____________________________________________________________
Note: If you are currently in therapy, you must have permission of your therapist to participate
on the Weekend.
The cost of the Weekend is $ 85.00* (includes meals and lodging). Please include a check for $20.00 as a deposit to reserve your spot. This deposit is refundable up to 7 days before the Weekend. The balance is due on or before the Weekend.
Checks should be made out to: Beginning Experience of Rochester
Mail to: Beginning Experience of Rochester Attn Overseer
PO Box 92248
Rochester, NY 14692
You will receive a confirmation of your application and depostit.
* Partial financial assistance may be available
What to bring for your Weekend:
Notebook and pen Comb/hairbrush Slippers
Warm comfy clothes Hair dryer Flashlight
Lawn chair Curling iron Coffee mug AND
Toiletries Towels/Washclothes travel container
Toothbrush, toothpaste Sleeping bag or
Soap twin sheets & blankets Snack to share
Shampoo Pillow Beverage to share
