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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)
What Armed Forces Base or First Responder Department are you associated with?
(For Example: Moody Air Force Base, Georgia Air National Guard, Warner Robins Army (retired) ,Henry County Sheriff Department, Georgia, Hamilton County Fire Department, Tennessee, Jonesboro Police Department, Jonesboro, Georgia, or None of the Above)
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)

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