Samaritan Counseling Center of Southern Wisconsin

                             2010 Pre-Marriage Program Registration Form

Names ______________________________  and _________________________________

Date of workshop________________   Your wedding date___________________________

Contact address: __________________________________________________________

City, State, Zip ______________________________________________________

Contact Telephone No.(s) Phones: (____) ____________________     (____) _________________________

Contact email: _________________________________________________________

Your present ages ________ /_________             First or second marriage?  Children and or Stepchildren?                  

Home Congregation(s): ___________________________________________________________

Officiating Pastor (s) Rev. _______________________________________________________

NOTE:  For the gold or platinum, you must call the Samaritan Center to set up individual appointment time to take the inventory and for feedback sessions. 

Silver Option            $95 per couple                     Date of Workshop  _______________

Gold Option              $325 per couple                   Date of Workshop  _______________

Platinum Option       $370 per couple                    Date of Workshop ________________

For credit card payments, please call the office.  Make checks payable to the Samaritan Counseling Center and mail to:

Samaritan Counseling Center
Water Tower Place 5900 Monona Drive Suite 100 Monona, WI 53716