INTERFACE^® MENTORING REGISTRATION

Name:    

Address:        Zip Code:  

Age: 20-2525-3535-4545-5555 & up     Home Phone:      Cell/Work Phone Number:

Email:

Occupation:      Marital Status (Please incicate): SingleMarriedDivorcedWidowed

(If Applicable) Number and ages of children:  Child care needed:NoYes

Register for the Interface^® God & Me Program ages 3-5 NoYes All child care reservations can be made by calling

 344-1203 ext. 131.  Please let Gaye know if you are registering for the Interface^® God & Me Program.

Church attending:     Christian? YesNo     If yes, how long?

Best day and time to be reached by phone:   

List Bible Studies, ABF classes, or other current involvement 

Share your expectations and hopes for a mentoring relationship

Indicate Best Time (B) and Worst Time (W) to meet for a 2 hour mentoring session:

Comments:

 For Child Care arrangements call 344-1203 ext. 131

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