Beginning Experience of Rochester, NY  -  Weekend Application
  May 18-20, 2018​ 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 is $190.00 (includes meals & lodging).  Include a check for $50.00 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.  

You can pay a deposit 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

You will receive a confirmation of your application and deposit.

Any questions Please call (585) 987-1750 or email

What to bring for your Weekend:
Notebook and pen              Comb/hairbrush                Slippers
Warm comfy clothes           Hair dryer                          Flashlight
Comfortable lawn chair       Curling iron                       Coffee mug AND
Toiletries                             Towels/Washcloths           travel beverage container
Toothbrush, toothpaste                   
Soap                                                                             Snack to share
Shampoo                                                                      Beverage to share

Weekend Application
Beginning Experience of Rochester NY

Serving the widowed, separated and divorced