Couples RETREAT Registration

COUPLES WORKSHOP / RETREAT REGISTRATION
Workshop Location & Date
CONTACT INFORMATION - PARTNER A
Partner A Name

First NameMiddle NameLast Name
Partner A Date of Birth

MonthDayYear
Date
Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
May we leave a message?
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
May we leave a message?
May we text you?
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
May we leave a message?
Email Address
example@example.com
May we email you?
Emergency Contact Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Relation to Emergency Contact
Race
Religion / Spirituality
Gender
Pronouns
Sexuality
Learning / Physical Ability Challenges
Additional personal / cultural identifiers you would like me to know
CONTACT INFORMATION - PARTNER B
Partner B Name

First NameMiddle NameLast Name
Partner B Date of Birth

MonthDayYear
Date
Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
May we leave a message?
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
May we leave a message?
May we text you?
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
May we leave a message?
Email Address
example@example.com
May we email you?
Emergency Contact Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Relation to Emergency Contact
Race
Religion / Spirituality
Gender
Pronouns
Sexuality
Learning / Physical Ability Challenges
Additional personal / cultural identifiers you would like me to know
Relationship Details
How long have you been in your relationship?
What if your favorite love song as a couple?
What is the current status of your relationship and what do you hope to gain from attending this retreat?
List three possible dates and times BOTH partners could complete a zoom interview for registration.
PARTICIPATION & REGISTRATION

You acknowledge that participation in this workshop / retreat is voluntary. You also agree that by registering that you are committed to participate in all scheduled retreat times. In order to reserve your space a non-refundable deposit must be received upon completion of the registration interview. The deposit amount is $300. The remaining balance of $695 is due 2 weeks prior to the workshop /retreat. Workshops are a non-residential. Participants are responsible for their own food and lodging. An interview is required to register for this retreat. The facilitators reserve the right to not admit participants who they deem not suitable to participate. To receive any discounts (if applicable) registration must be completed one month prior to the workshop /retreat. Retreat pricing will vary based upon location and what is offered by the host facility.

MODALITIES

Getting the Love You Want is created by Imago Relationships. The workshop facilitators are trainined in Imago Relationships, The Gottman Method, Exceptional Relationships and Core Energetics.

RECORDING

Portions of the workshop will be recorded. The recordings will only be used in supervision with Imago teachers. By participating in the workshop, you grant David & Bentley deBardelaben-Phillips and Clare Carr the right to:

1. Record your likeness (still and moving images) during workshop sessions.
2. Record your voice during interactive sessions, discussions, and Q&A portions.
Agreement
Release of Liability
Partner A - By typing my full name below and signing this form, I am affirming that I have read, understood, and agree to be legally bound by the Release of Liability and Participation & Registration terms.

First NameLast Name
Partner A Signature
Partner B - By typing my full name below and signing this form, I am affirming that I have read, understood, and agree to be legally bound by the Release of Liability and Participation & Registration terms.

First NameLast Name
Partner B Signature
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COUPLES WORKSHOP / RETREAT REGISTRATION

CONTACT INFORMATION - PARTNER A

CONTACT INFORMATION - PARTNER B

Relationship Details

Release of Liability

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