ReEngage Couple Registration
Husband's Name
*
First Name
Last Name
Wife's Name
*
First Name
Last Name
Anniversary Date
*
-
Month
-
Day
Year
Date
His Birthday
*
-
Month
-
Day
Year
Date
Her Birthday
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
His Cell
*
Please enter a valid phone number.
Her Cell
*
Please enter a valid phone number.
His Email
*
example@example.com
Her Email
*
example@example.com
Will you need child care? (Available Birth - 5th grade)
*
Yes
No
List each child's First Name, Last Name, and Date of Birth
Church you most regularly attend (write N/A if you don't attend church).
*
Where did you hear about ReEngage?
*
Please Select
A friend or family member
Church slide or bulletin
Social media
Online search
Other (explain)
If "other", enter where you heard about ReEngage:
Please mark all that apply
*
Married
Separated
Divorced
Blended Family
Do you both agree to attend at least 80% of the weekly meetings between January 10, 2024 and May 22, 2024
*
Yes
No
I need to talk with someone about schedule conflicts.
What is the biggest challenge in your marriage right now? (optional)
Questions or comments:
Register
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