| Participant Information: |
*Required |
| *Last Name: |
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| *First Name: |
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| *Address: |
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| *City, State, Zip: |
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| *Home Phone: |
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| Work Phone: |
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| Cell Phone: |
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| E-mail: |
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| *Date of Birth: |
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| *Gender: |
Male
Female |
| *Marital Status: |
Married
Separated
Divorced
Single |
| *For the purpose of the database, has your
name recently changed?
Yes
No |
If yes, what was your former last name?
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| *Have you recently changed your address?
Yes
No |
If yes, what was your former address?
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| I currently attend Hope Community Church services (check
all that apply): |
Occasionally
Three or four times a month
I’m in a small group
I attend another church regularly
I do not attend church at this time. |
| Which statement best describes your current belief in
God? |
God is not a part of my life right now.
I am interested in learning more about God.
I believe in God and sometimes pray.
Jesus is the leader and forgiver of my life. |
| *Have you attended a previous Marriage Matters Workshop?
Yes
No |
If yes, who was the leader?
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| Would you like to be placed in the same group?
Yes
No |
| GROUP PLACEMENT |
| For best placement within a Marriage Matters
group, please provide the following info: |
| *On a scale from 1-10, rate the health of
your marriage.
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*What is one reason for this rating?
Struggling with resolving conflict
Communication problems
Sexual intimacy
Sexual addiction
Finances
Blended family issues
Doing well overall, want to strengthen marriage
Other |
Please explain:
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| *Date of Marriage |
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| *Have you been married previously? |
Yes
No |
| *Are you a blended family? |
Yes
No |
*What are your children’s dates of birth?
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| Do you need childcare for the workshop? |
Yes
No |
If Yes, please list the number of children and ages of the children.
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| *Is your spouse registering for this workshop as well? |
Yes
No |
*What is your spouse’s full name?
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Is there anything else that would be good
for us to know as we consider your group placement?
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Please submit payment ($30 per couple/$15
per person)
upon
attendance at the first night of the workshop. |
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