First Name
Last Name
Title
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
FAX
E-mail
Check which day(s) you prefer to meet:
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Check which day(s) you CANNOT meet:
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Your Age Group:
18-24 25-32 33-41 42-55 55
Your Marital Status:
Single Married Partner Other
Age(s) of Children
Infants Toddlers/Preschoolers Elementary Adolescents Adults
What Purposes do you want your Small Group to focus on? (1=no focus, 5=a lot of focus)...
1 2 3 4 5
Worship
Fellowship?
1 2 3 4 5
Evangelism?
1 2 3 4 5
Discipleship (Bible Study)?
1 2 3 4 5
Service?
1 2 3 4 5
Comments or Questions?
How many years have you been attending our Church?