Date: _______________

Last Name: ________________________________________________________

First Name: H_________________________W____________________________

Street Address: ____________________________________________________

City: ______________________ State: ______ Zip: __________

Home Phone Number:____________________(You must include a phone number so we can contact you.)

Work Phone Number:____________________

E-Mail:__________________________________________________________

Wedding or Ordination Date: __________________________________________

Religion: H__________________________W____________________________

Parish/Church/Synagogue: ___________________________________________

We heard about Marriage Encounter From:

_______________________________________________________________

_______________________________________________________________

We would like to make our weekend beginning Friday:

1st. Choice _________________________________________

2nd. Choice _________________________________________

With Registration: I've enclosed $50.00 check for non-refundable payment.
$40.00 if paid 2 weeks in advance of the weekend.
(Make check payable to World Wide Marriage Encounter)
Or, by Credit Card: Charge my non-refundable registration to my credit card, indicated below:
Credit Card Information: Visa, MasterCard

Card Number _________________________________________

Expires __________

Name on Card ________________________________________

Signature ___________________________________________

Registration Couple, Deb and Steve Robbins 307-686-7471
Their e-mail is: sdrobbins@bresnan.net
Mail registration to:
Wyoming Marriage Encounter
811 Pioneer
Gillette, WY 82718

E-mail questions to Wyoming World Wide Marriage Encounter at: encounter@wyomingwwme.org
Please include a phone number and the best time to call so that we can get back to you and answer your questions.