Submitting your application for the
PREPARED COUPLES/SINGLES PROGRAM is easy.

You can download your form here fill in all the required information and email it back to prepares-marriage@rtv.org or simply scroll down the page and fill in our online application.

Once we receive your application our program staff will review it and get back to you regarding acceptance and further details on the program.

PREPARED COUPLES ENROLLMENT FORM

Adult enrollment form to capture personal data

• Married or Single?*
  • Married
  • Single
• Enter Your Name*
  First Middle Last
• Your Date of Birth*
  MM slash DD slash YYYY
• Enter Your Race/Ethnicity*
  • Asian
  • Black/African American
  • White
  • Multiracial
  • Non-Hispanic
  • Hispanic
  • Haitian
  • Other
  What race you identify as.
• Enter Your Email Address*
• Mobile Phone Number*
• Name of Your Spouse
  First Middle Last
  Disregard if you are signing up as a Single
• Date of Birth Of Your Spouse
  MM slash DD slash YYYY
• Your Spouse Race/Ethnicity
  • Asian
  • Black/African American
  • White
  • Multiracial
  • Non-Hispanic
  • Hispanic
  • Haitian
  • Other
  What race you identify as.
• Enter Spouse Email Address
• Spouse Mobile Phone Number
• Address
  Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country
• Number of Children
  012345678910
  How many children you have, if none select 0.
• Wedding Anniversary Date
  MM slash DD slash YYYY
  Disregard if you are signing up as a Single
• Members of Household*
  01234567891010 >
  How many children you have, if none select 0.
• Annual Household Income*
  $0 - 20,000$20,000 - $40,000$40,000 - $60,000$60,000 - $80,000$80,000 -$100,000over $100,000
  Incomes under $60,000 receive free services.
• Other Income/Benefits
  • Received Food Stamps (past 6 months)
  • Disability
  • Receiving TANF Benefits
  Please select all that apply.
• Tee Shirt Size*
  X-SmallSmallMediumLargeXLXXL3XL
• Men's Shirt Size*
  14151618
• Women's Dress Size*
  24681012141618202224
• Referred by
• Referred from
  • Church
  • School
  • Organization
  • Other
• Referring Organization
  Add name of organization who referred you.
• Consent*
  I agree to the privacy policy.
  I, the undersigned, hereby give permission to participate in the ReCapturing the Vision Intl, Inc. (RTV) Marriage Program. In doing so, I do hereby waive, release and forever discharge RTV, their agents, employees and anyone else connected with this activity from any and all harm resulting from injuries sustained as a result of my participation. I also grant the right to administer all medical services that may result from injuries during participation, including emergency and referral if necessary.
  
  The RTV Marriage Program has my permission to use any and all photographs taken of me in advertising and promotional materials. (Strike this sentence if you do not want to give permission and initial.)
  
  I certify that I have an understanding of this agreement and any risks and hazards associated with the activity described above that I will be participating in. I further understand that I have the opportunity to fully discuss this agreement and/or the curriculum and program.
• Email
  This field is for validation purposes and should be left unchanged.

The Program will focus on relationship enhancement for couples and singles. PREPARED COUPLES/SINGLES PROGRAM will provide a host of activities that will strengthen, enlighten and provide fun engagement for all participants. It includes 7 date nights free of charge to couples or singles who commit to completing the full project offerings. All date nights also include complimentary food and beverage. Date nights occur on Friday evenings and provide immersive marriage and relationship education.

You will receive services supported by federal funds, and, as such, the program will not teach or promote religion. Marriage Education will be the messages taught in the program. If you have any questions about our program or organization, you can contact Myra Brown, Program Director, at (305) 232-6003

SURVEY QUESTIONAIRES: As part of the evaluation of this program, you may be asked to complete a survey up to three times: at the beginning of our program year, at the end of our program year to measure changes in knowledge, attitudes , and behavior related to marriage and if possible up to 120 days later.

Answers to the survey are strictly confidential! Your name will NOT be on the survey. The answers provided will be combined with answers from all other participating couples. You will never be identified by name in any evaluation reports.

Your participation in completing the survey questionnaire is mandatory. Your commitment will help us to learn more about behavior and attitudes, and to develop effective marriage programs.

Recapturing the Vision

11205 South Dixie Hwy

Suite 201

Miami FL 33156

Phone: 305.232.6003

Contact Us