Name:

Home Phone:

Last                              First                               M.I.

Cell Phone:

Age:

Work Phone:

Address:

Street, Apt.#

City

                   State                         Zip

Are you currently employed?

Yes

No

If so, where:

Child(ren)

Name

(First Name Only)

Age

Gender

School Grade

Are you currently attending a church?

Yes

No

If so, please note the name of the church:

Would you like to stay overnight in a host home?

Yes

No

Will you need childcare?

(Overnight not provided for children)

(Circle) Day Session / Evening Session / Both

Yes

No

Home Organization

Healthy Relationships

Budgeting

Car Maintenance

Positive Parenting

Available Government Programs

Dress for Success-Interviewing

Divorce Recovery  

Quick & Easy Microwave Meals

Other:  ___________________________

(Office Use Only)

$10.00 Commitment Fee

Paid

Check

This Commitment Fee Will

Received By: (Initials)

Cash

Be Returned on Feb. 20th

To Attendees