SMALL GROUPS INTEREST SURVEYPlease fill out the survey as completely as possible. The information will help us in determining how best to place you with a group. All information will be kept private and will be used solely for small group placement purposes.
Name
Street Address
City, State, Zip
Phone # you prefer to be contacted thru
Email address you check regularly
Marital & Family Status Please select the option which BEST describes you and your familyNewleywedMarried, no childrenMarried with childrenBlended familySingle, never marriedSingle parentSingle, divorcedSingle, widowed
Your age category Please select20's30's40's50's60'sI don't want you to know!
If you have children, please indicate their ages
What type of group would interest you? Check all which apply: Couples Mixed (couple & singles) Singles Men only Women only Life Stage Family (parents & kids study together) Interest-based Neighborhood group Young adult
How far are you willing to travel to attend a group? 0-5 miles0-10 miles0-20 miles0-30 miles
Would you have any interest in HOSTING a group in your home? Yes No
Have you ever been part of a small group before (here or somewhere else)? If yes, please describe your experience:
Please select all times during the week which would be options for your participation in a group Mondays Tuesdays Wednesdays Thursdays Fridays Saturdays Sundays Morning Afternoon Evening
How soon would you like to be placed in a group? As soon as possibleSummer 2008Fall 2008Winter 2009