Pay by Check

COUPLES WORKSHOP REGISTRATION
Paying by Check

Fill out the form first, then print and mail with your personal check to Rod Kochtitzky.
After printing, please hit the submit button to reserve your spot for the workshop.
PLEASE NOTE: You must print and mail the completed form with your check.

MAKE CHECKS PAYABLE TO:
Rod Kochtitzky

Pastoral Center for Healing

South Hall Woodmont Christian Church
3605 Hillsboro Pike, Nashville, TN 37215
Phone Message: (615) 385-3838

Your name:

Partner's name:

Address:

City:

State: Zip:

Your E-mail:

Partner E-mail:

Daytime phone:

Evening phone:

Special contact instructions:

Getting the Love You Want: Couples Workshop
$750.00 per couple if registering 2 weeks in advance.
$795.00 if registering 13 days or less before workshop.
Seminars - Please enter amount: $

You are paying by sending a check.

Please enter the date it will be mailed:

Date of Workshop you want to attend:

Are you currently in therapy?

If so, which category?

If so, with whom?

(Please discuss attending this workshop with your therapist.)

How did you hear about this Workshop?

T H A N K Y O U !