Small Group Intake Form

If you would like to commit to a small group, please fill out the information on this form. All fields marked with * are required.

In order for a group to effectively join togther they just share time and experiences, and we have found that a minimum of three hours every two weeks is necessary.  How are you preparing your schedule to accommodate time for this group?

Note: Placement can sometimes take several weeks or even months. Please be patient as we recruit and equip new leaders.

* First Name:
* Last Name:
Home Address:
City:
Postal Code:
Home Phone:
Work / Cell Phone:
* Email:
Service Attending: 9:30 am 11:15 am 6:00 pm
* Gender: Male Female
* Birth Year:
Student:
School:
Program:
Current year of program:
Anticipated Graduation:
Marital Status:
Children at home:
Days that work for you: Mon Tue Wed Thu Fri Sat Sun
Frequency: Weekly Bi-weekly
Time of Day: Evening Day Time
Geographic Area: I would prefer a group in my area.
Age Preference
Gender Preference
Marital Preference
Children Preference

I would like to be in a group with my friend / significant other / spouse:

I would be willing to be a leader or apprentice leader.

Additional comments



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