Couples Workshops - Registration
 
Mona Barbera
Couples Workshops

SAMPLE ONLY NOT FOR CURRENT REGISTRATION Registration Form



To Register for the next Bring Yourself to Love weekend couples workshop, mail this registration and your check made payable to Mona Barbera, Ph.D.,  341 Broadway, Providence, RI 02909

Dates and Times:
xxxxxxxxxxxxxxxxxxxxxx

xxxxxxx

Location: xxxxxx

Fee per couple: fees will be available closer to the time of the workshop

Refund Policy: We will refund your registration minus a $15 processing fee only if we can replace you with someone on the waiting list.  

Please print this page and fill-in the form below:

Name (1) _________________________________________________________

Name (2)__________________________________________________________

Address___________________________________________________________

Emails_____________________________________________________________

Phones (H)___________________________(W)___________________________

(Cells)_____________________________________________________________

Date of registration_______________________

Who referred you to this workshop?_______________________


Special Needs:





 

Note: Bring Yourself to Love weekend couples workshops may not suitable for couples in which one or both partners are currrently suicidal.


© 2009 Mona R. Barbera. All Rights Reserved.