of the Low Country - South Carolina

The Beginning Experience Ministries
Please fill in all fields!

Full Name: 

Preferred First Name: 



State:  Zip:  
Home Phone:

Work Phone:

Email Address:
Age: How old are you?


Status: Separated  Divorced  Widowed  -  How Long?
Marriage:   How long were you married? How many times?
Children:   How many? Ages: 
Weekend: Have you ever attended a TBE weekend before? Yes No
Church: Name of Church you attend:
Are you currently in any Counseling or Therapy? Yes No
If so, name of Counselor or Therapist:
Counselor/Therapist Address: Address City State Zip
Carpool: Would you like to ride with the Carpool? Yes


How did you hear about the weekend?
Who do you know attending this weekend?
Whom to notify in case of Emergency:
(Enter full name, address and phone number(s))
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A weekend program designed to help people who are widowed,
 separated or divorced
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