First Name (Husband): *
First Name (Wife): *
Last Name: *
Street Address: *
City: *
State: *
Zip: *
Home Phone: *
E-mail Address: *
Please re-enter your email address: *
Select your preferred weekend: (one selection) *	Nov. 14-16, 2008 at Capuchin March 27-29, 2009 at Manresa August 7-9 at Capuchin Sept. 25-27, 2009 at Manresa Nov. 13-15, 2009 at Capuchin
Please identify any special needs: dietary restrictions, longer bed, handicap accommodations, or difficulty with stairs.
How did you hear about National Marriage Encounter? (Please pick best selection) *	Church Bulletin Web site Email Brochure Radio (WDEO or other) Personal Referral Other
Please identify the Church you attend most often: (optional)


* Required