Today’s Date

Weekend Choice

I’m interested in finding out more about the Beginning Experience weekend.

Name

Address

City / State / Zip

Contact Number

Email Address

Best time to be contacted

How long have you been single?

Are you

__Separated    __ Divorced     __Widowed

Your age group

20-29, 30-39, 40-49, 50-59, 60+

How did you hear about the Beginning Experience weekend?

What do you hope to gain from the weekend?

Are you currently in a support group?

Are you currently in counseling?

Please send to :

Beginning Experience New Hampshire Team

1500A Lafayette Rd #282

Portsmouth, NH 03801-8607