Rebuilders: Overcoming Divorce Spring 2006

D i v o r c e R e c o v e r y Date:______Fall 2012 Second Baptist Church – Woodway (Please PRINT ALL Information Legibly)

Name: ______Title: ______(First) (Middle/Maiden) (Last) (Dr., Mr., Mrs. or Ms.)

Preferred name on name tag:______

Date of Birth: ______Age: ______(Month/Date/Year)

Address: ______(Street Address) (Apt)

______(City) (State) (Zip Code)

Email Address: ______

Best Contact Phone # and type (cell, home or work):______

Church Membership: ______(Church) (City) (State)

Bible Study Class at Second Baptist Church: ______

How did you hear about this class? ______

(The Following is REQUIRED for Arranging Small Groups) P l e a s e C i r c l e M a r i t a l S t a t u s: Married Separated Divorced Widowed Single Parent Never Married

How many years ______and/or months ______(In regard to the above status)

Circle Your Age range: 20’s 30’s 40’s 50’s 60+

Do you have a friend or relative attending this current Divorce Recovery session? Yes No

If yes, name:______

If you are a Single Parent, are you the Custodial or Non-Custodial parent? (please circle) Information for Children 18 and younger only:

Name: ______Age: ______Grade: ______First Middle Last Name: ______Age: ______Grade: ______First Middle Last Name: ______Age: ______Grade: ______First Middle Last