Freedom Session 2017-2018 Registration Form
All the information in this form will be held in confidence and used only for the purposes of serving you in the Freedom Session ministry.
Email address
Personal Information
The information collected in this part of the Registration Form will be passed along to the Facilitators in the Freedom Session Ministry as needed. Please include FIRST and LAST NAME
Name
Your answer
Address
Your answer
City
Your answer
Postal Code
Your answer
Phone
(Indicate if home or cell phone and if it's ok to communicate by text)
Your answer
Email
Your answer
Age
Your answer
Gender
Required
Marital Status
Required
Additional Information
The information collected in this part of the Registration Form will be passed along to the Facilitators in the Freedom Session Ministry as needed.
Have you attended Freedom Session before?
If yes, WHEN and WHICH GROUP were you in and STEP COMPLETED.
Your answer
Have you attended other recovery programs?
If yes, WHEN and WHICH PROGRAM and WHERE?
Your answer
How did you hear about us?
Your answer
Do you attend South Abbotsford Church?
Do you attend another church? If so, which one?
Your answer
Are you currently under the care of a counselor, psychologist or psychiatrist?
If under the care of a counselor, psychologist or psychiatrist, are they in favor of you participating in Freedom Session?
Your answer
Are you taking any medication prescribed by a doctor, psychologist or psychiatrist? If yes, please explain
Your answer
Consent / Registration Form - I (print your name) __________________________________________________ hereby give consent to the organization/church, to which I am handing in this form, to use the following personal information for my pastoral care, participation in church related activities and emergency care. I understand that my personal information will only be given to pastoral and/or church staff, program leaders, event coordinators and emergency personnel on a need to know basis. My personal information will be securely stored in an appropriate place, and will not be passed on to any third parties without my/our prior consent. By signing and dating this Consent form I indicate that I have read, understand and approve the above and that this information will be stored for a minimum of one (1) year. Signature _____________________________________________ Date ___________________________________ (please type name in box below)
(A printed version of this form will be available for you to sign in person at the first Freedom Session Meeting you attend)
Your answer
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