Print this form, fill in the requested confidential information.  Mailing instructions are at bottom of page.
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First Name:  ______________________Last Name:  __________________________

Address:  _________________________________________________________________

City:  ____________________________State:  _______ Zip:  ______________

Phone (home): _______________________Phone (work): _____________________

Email address:  __________________________________________

Have you attended before?

_____  Yes

_____  No

Age:  _____Gender:  _____How long married?  _______How long separated or divorced?  _______

Do you have children?

_____  Yes

_____  No

Are you registering your child for the Children's Program?   ____Yes    ____No

1. Child's Name: __________________________Age:  __________

2. Child's Name: __________________________Age:  __________

3. Child's Name: __________________________Age:  __________

How did you hear about Beyond Divorce?

 _____ Flyer at Church.  If so, which church? __________________________________

 _____  Through a Friend _____   Seattle Weekly

 _____ Newspaper Ad  ______   Radio Ad

 _____ On the Internet

After filling out form, please mail it with (recommended), or without, your registration fee ($55 first time, $20 alumni, kids FREE) to: