Request Form To Host Seminar

Organization Name*

Desired date to host seminar

Address*

Street Address City State ZIP Code

Approx number of members in your organization

Our organization's web site

Primary Point Of Contact (POC)

Name*

First Last

Email*

Phone*

Phone Number Is...

Phone number is

Office
Cell
Home

Best Time To Call...

Best time to call

8:00 am - noon
noon - 4:00 pm
4:00 pm - 8:00 pm

Alternate Point Of Contact (Optional)

Alt POC Name

First Last

Email (Alt POC)

Phone (Alt POC)

Phone Number Is...

Phone number is (Alt POC)

Office
Cell
Home

Best Time To Call...

Best time to call (Alt POC)

8:00 am - noon
noon - 4:00 pm
4:00 pm - 8:00 pm

Check those that apply

Divorce Care or Divorce Recovery is offered in our area
We are willing to open attendance to other organizations in our area; i.e. Salvation Army, churches of other denominations and affiliations, or community relief organizations.

Other information we feel we should know about to help us tailor the weekend for our attendees.

Upon receiving your request, one of our Directors will be assigned to you as a POC to Families By Design USA. We will send you an Introduction Package outlining for you and your decisions maker(s) what we are about and what it takes to host an event.

We prefer to have the Introduction Package sent via*

Electronically (PDF Attachment)
Postal Mail

Date we expect to make a decision:

Visitors