Serving Marriages

All information remains strictly confidential. Information, when submitted, is merged into a group summary report,
which cannot identify any spouse or couple.

Retreat Name
Husband's First Name
Husband's Last Name
Wife's First Name
Wife's Last Name
Mailing Address	City State Zip
Email address
Alternate Email address	(not required)
Phone contact
Alternate phone contact	(not required)
Husband's Age
Wife's Age
Years Married
Do you require a handicap room?	No Yes
Do you have any dietary restrictions?	No Yes
If yes, please explain your dietary restrictions and needs:

Have you attended a Serving Marriages retreat before? Yes No

If you are serving or have served in the Armed Forces or as a first responder, please identify:

Air Force	Army	Marines	Navy
Coast Guard	Law Enforcement	Fire	EMS
None of the Above Other (Specify)

How did you learn of our retreat?

	Friend or Family Member	Previous Retreat Participant	Internet
	Church	Media	Other (Specify)

What circumstances cause the most tension in your marriage?

Raising Children	Finances	How you spend your time
Communication Issues	Friendships	Housework
Faith differences	Other (Specify)

Rate Your Marriage 1 2 3 4 5 6 7 8 9 10

1 Seriously considering divorce
and 10 being fantastic

"To the angel of the church in Philadelphia write: These are the words of him who is holy and true, who holds the key of David. What he opens no one can shut, and what he shuts no one can open." (Revelation 3: 7-10; NIV)