Last Name _________________________ His First/Nickname _____________________


Her First/Nickname _____________________  Wedding Date _____________________


Street Address _____________________________________________________________


City ____________________________ State ______________ Zip _________________


Home Phone (     ) _________________ Business Phone (     ) ________________


E-mail address ________________________ Home church ________________________


We learned about M.E. from _________________________________________________


Special Needs: ___ Dietary  ___ Medical  ___ Mobility ___ Other ____________


Please explain special need: _______________________________________________


Send $50 nonrefundable fee payable to Marriage Encounter

Mail to: Scheduling Couple
         Eugene & Roberta Clausen
         1201 High Plains Circle
         Lincoln, NE 68512

         (402) 435-5006
         Email: This email address is being protected from spambots. You need JavaScript enabled to view it.