Today’s date _____________________________________________________

[ ]  I'd like to attend a Beginning Experience weekend. Please call me.

[ ]  I want to know more. Please contact me.

Name ____________________________________________________________________________________

Address	_________________________________________________________________________________

City _____________________________ State ________________    Zip ________________________

Home phone _________________________________ Work phone _________________________________

Cell phone _________________________________     E-mail _________________________________

Name/phone of emergency contact _________________________________________________________

Religious affiliation/parish ____________________________________________________________

How long were you (Years/months)

_______/________ Married?                                       Age _____________________

_______/________ Widowed?                                       Sex _____________________

_______/________ Divorced?                       Number of children _____________________

_______/________ Separated?                         Children's ages _____________________

How did you hear about the Beginning Experience program? ________________________________

_________________________________________________________________________________________

What do you hope to gain from the program? ______________________________________________

_________________________________________________________________________________________

Do you have any special needs we should be aware of such as physical or dietary

limitations?  [ ] Yes   [ ] No    If yes, please specify ________________________________

Are you presently in counseling/therapy?        [ ] Yes   [ ] No

If yes, please supply us with a written approval to attend from your therapist.

Comments: _______________________________________________________________________________

_________________________________________________________________________________________

Date of Beginning Experience weekend desired: ___________________________________________

Please mail completed application to:
     Beginning Experience of Seattle
     9594 First Ave. NE  #302
     Seattle, WA  98115-2012

[ ] $25 nonrefundable deposit enclosed