Register for the Couples Workshop

NOTE: each box with asterisk must be answered to complete your Registration

Two Methods for easy registration,

  1. Fill out the Registration Form, select Pay by Check (greatly preferred) and click “Click Here to Register”, then submit payment via check sent to the address at the bottom of the page…OR,
  2. Fill out the Registration Form, select Pay by Credit Card and click “Click Here to Register”, then click “Buy Now” to visit Google Check Out and pay using a credit card.

Select Workshop Date:*

Contact Information:

First Name*

Last Name*

Address*

Apt/Suite:

City:*

State:*

Zip Code:*

Phone (Home):*

Phone (Work):

Phone (Cell):

Email:*

Partner Contact Information:

Partner First Name:*

Partner Last Name:*

Partner Address:*

Partner Apt/Suite:

Partner City:*

Partner State:*

Partner Zip Code:*

Partner Phone (Home):*

Partner Phone (Work):

Partner Phone (Cell):

Partner Email:*

Misc:

How did you learn about us?:

Other (please specify name):

Whom may we thank for their recommendation of the Imago Couples Workshop to you?:

(located here)

Registration Amount

Payment Method

Please be sure to click the ‘Click Here to Register’ button and wait for the Confirmation Message to display before selecting a Buy Now button below.  These buttons below are only if you wish to pay with a credit card.  If your desire is to pay by check, simply mail your check asap (within 24 hours max) to 4212 San Felipe, Suite 143, Houston, TX  77027-2902. Make it payable to Damian Duplechain LPC, Inc. in order to continue to hold your Workshop slot.  Under no circumstance should you select a Buy Button below, or leave this page before you have FIRST clicked the ‘Click Here to Register’ button above.

 

 or
$350 Deposit $700 Full Registration

NOTE: Total fee balance is due no later than 14 days before the Workshop, i.e., the 2nd Friday before your Workshop weekend.

NOTE: Registration confirmation will be emailed within 48 hours with Directions, Instructions, and Area Hotel Info.