SIGN UP FORM (Print and Mail)
(please sign up by February 28th)

Seven sessions: Saturday mornings March 10th to April 21st from 10:00 - 11:30 am for $245 total cost.

His Name: ________________________________________________

Her Name: ________________________________________________

Address: __________________________________________________

City, State, Zip: _____________________________________________

Best reached at this phone: ____________________________________

Email address(es): ___________________________________________

___________________________________________
Payment:
Check enclosed for $245. Check number: ____________________
Credit card number: _____________________________________
Expiration Date: ________________________________
Name on Credit Card: ____________________________
Type (VISA, Master, etc.): ________________________
Cash (do NOT mail cash, must be delivered by sign up date above)

Where would you like the receipt to be sent?
email address
home address
Please mail this form to:

Carol L. Brown, LMFT
Christian Marriage Center
13911 Ridgedale Drive, Suite 460
Minnetonka, MN 55305