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Please take a few minutes to complete this form. Your individual responses and personal information will remain confidential.

1. Select the five most important issues you think we should address in the next year. (Please number from 1 to 5, with 1 being most important.)

Spiritual Growth

Bible Knowledge

Evangelism

Missions

Mentoring

Marriage

Fathering

Friendships

Sexuality

Physical Fitness

Life Purpose/Calling

Job/Career

Finances

Time/Priorites

Male Passivity

Emotional Balance (anger, fear, hopelessness)

Domestic Violence

Pornography

Substance Abuse

Other:

2. Check one primary area of ministry you’d be willing to serve in:

I'm willing to be a point man (primary coordination.team leader) for this area:

3. Your name:

(First)

(Last)

4. How should we contact you? (Complete and check all that apply.)

Mailing Address

Street:

City:

Zip:

Apt:

Home phone:

(

)

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Work phone:

(

)

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Cell phone:

(

)

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E-mail:

What's the best way to contact you. (Select one.)

What's the best time to contact you. (Select one.)

Would you like to receive periodic updates on ministry to men?

5. When is your birthday?

6. Are you married?

7. Total number of children:

Number of children living at home: