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 Blended Family 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? Security code:   * Do not enter anything in this field: