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.