Today’s Date:



PREPARE PROGRAM REGISTRATION Date: __________

Thank you for your interest in the UGA ASPIRE Clinic’s premarital education program, Prepare! It’s great that you and your partner are willing to put time and energy into enriching your relationship. To schedule you for meetings with a facilitator, please provide some background information that will help us know a bit more about you and your partner. Once this registration form is received, you will be contacted regarding scheduling by the ASPIRE Clinic’s Coordinator.

Primary Contact’s Information

|First & Last Name: | |Birth Date | |/ | |/ | |Age: | |

|Address: | |

| |Street Apt. # City State |

| |Zip Code |

|Preferred Phone | |Best number to call you: | |

|Best times to call: | |OK to leave a message? | |

|Email | |

Partner’s Contact Information

|First & Last Name: | |Birth Date | |/ | |/ | |Age: | |

|Address: | |

| |Street Apt. # City State |

| |Zip Code |

|Preferred Phone | |Email: | |

Participation in (and completion of) this program will qualify you for a $35 discount on your GEORGIA marriage license. We will provide you with a notarized certificate at the end of the program if you are interested.

|Have you filed for your marriage license? | |Yes | |No |

|Are you interested in receiving this marriage license discount? | |Yes | |No |

|Wedding Date: | |

| |

|Currently, we are only offering the Prepare program to couples in one-one-one sessions. There is a minimum of 6 classes, and each session lasts for |

|approximately 1.5-2 hours. Cost: $120 (includes couple workbooks). An additional $34.95 is collected online to complete the required inventory - See page |

|2 for more information. |

| |

|Total Cost (all sessions, materials, & online inventory): $154.95 |

| |

|All sessions are held at the ASPIRE Clinic at the University of Georgia in Athens, GA. () |

| |

|To help us schedule, please check all the days/times you and your partner are available. |

| | |Mon |Tues |Wed |Thurs |Fri |

|Please check boxes or write|Morning (9-12) | | | | | |

|in exact hours you are | | | | | | |

|available. | | | | | | |

| |Daytime (12-4) | | | | | |

| |Evening (5-8) | | | | | |

| |Website | |Community Event | |Friend/Family | |Probate Court/Marriage License Bureau |

| |Pastor/church | |Government office/program | |Other: | | |

Brief Description of the PREPARE Program:

PREPARE is a research-based program that is designed to help you build a stronger and happier marriage. Participation in the PREPARE program requires that you and your partner complete a couple inventory which will identify your strengths as a couple and areas of growth in a variety of areas (e.g., communication, conflict resolution, personality issues, financial management, children & parenting, family & friends, expectations, family-of-origin experiences). Each inventory is customized based on the couple’s background and interest. The PREPARE program will consist of six 1.5 - 2-hour sessions where we will focus on (1) your strengths/growing areas; (2) communication; (3) managing conflict; (4) family life experiences; (5) financial plans and budget; and (6) setting goals.

To help us match you with the right inventory, please answer the following questions:

|Q2. Do you and your partner currently live together? | |Yes | |No |

| | | | | |

|Q3. Have you or your partner been married before? | |Yes | |No |

| | | | | |

|Q4. Do you or your partner have any children together? | |Yes | |No |

| | | | | |

|Q5. Do you or your partner have any children from a prior relationship? | |Yes | |No |

| | | | | |

|Q6a. Do you have access to a computer with internet access? | |Yes | |No |

| | | | | |

|Q6b. Does your partner have access to a computer with internet access? | |Yes | |No |

| |

|Thank you for this information. |

| |

|Please email (aspire@uga.edu) your completed form to |

|Megan Ford, ASPIRE Clinic Coordinator. |

| |

|Questions? Call Megan Ford at the ASPIRE Clinic at 706-542-4486. |

| |

|Office Use Only | | Couple ID: | | |

|Assigned Facilitator | | | | |

|Inventory | |PREPA|

|Assigned: | |RE |

|Session Format: | |One-on-One | |One-day Weekend: | |

|Session Date(s): | | |

| | |

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