WorldWide Marriage Encounter on Long Island


	Complete the form below to apply for a space on an upcoming Marriage Encounter weekend


	Weekend Date Preferred:


	Last Name:


	His First Name:


	Her First Name:


	Address:


	Address (if required):


	City:


	State:


	Zip Code:


	His Faith:


	Her Faith:


	Parish/Church/Synagogue:


	Wedding Date:


	Daytime Phone Number:


	Evening Phone Number:


	Email Address: