Illuminate the Path Registration Form — Illuminate the Path Coaching

WHAT’S NEXT?

Please complete the following Form in order to complete your Registration

Details about the weekend and its location will be sent to you in a few weeks.

Husband’s Name

First Name

Last Name

Wife’s Name

First Name

Last Name

Mailing Address

Husband’s Email Address

Husbands Phone

Country

(###)

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Wife’s Email Address

Wife’s Phone

Country

(###)

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Emergency Contact Name and Phone Number

Country

(###)

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Years Married

Number of Children and Ages

It would be helpful for spouses to have a brief discussion about the following questions and answer as a couple:

Tell us a little about your marriage, how the SSA issue has impacted your life, your hopes and expectations for your future.

Do you have medical insurance and/or the financial resources to pay for health care should it become necessary during or as a result of your participation in the Together In Love Couples Weekend?

Do either of you have any physical limitations or health issues that we should know about?

Yes

Are you currently under the care of a medical professional for any reason?

Yes

Are you taking prescription medications for any reason?

Yes

If you answered yes to any of these, please explain.

Do you have any dietary restrictions? P lease provide details below: