Program Registration Form
Check the program you are registering for:
First Name: Last Name:
Gender:
Address:
City: State: Zip Code:
Home Phone: Cell Phone:
Email:
Date of Birth:
Marital History:
How long were you married?
Separated: How long ago? Are you considering reconciliation?
Divorced: How long ago?
Widowed: How long ago?
Number of Children: Ages:
Religion: Parish/Church:
This Beginning Experience Program is appealing to me because
What do you hope to gain from the program?
How did you hear about BE?
Physical or dietary limitations we should be aware of?
Are you currently in counseling?
If yes, please inform your therapist before participating in our program(s).
Signature: Today's Date:
Cost of Beginning Experience Programs:
•
COPING WITH LIFE ALONE: $50. Fee includes lunch & materials. Payment required by check with registration form.
•BE WEEKEND PROGRAM: $200 (shared room) or $245 (private room). $75 deposit required with registration form and can be paid by check or by card at the below link. Deposit is refundable if you cancel at least 7 days before start of program. Balance to be paid upon arrival to weekend program. Fee includes lodging, meals and materials.
•REBUILDING SUPPORT GROUP: $40. Payment required by check with registration form. Fee does not include the book and workbook which can be purchased from Amazon or other retailers.
You can pay the BE Weekend deposit of $75 by credit card at
Checks should be made out to: Beginning Experience of Rochester
Mail to: Beginning Experience of Rochester ~ PO Box 92248 ~ Rochester, NY 14692
After submitting this form, you will receive a confirmation of your registration by email within 5 business days.
