Personal Profile

Name:
Street Address:
City:
State:
Zip Code:
Daytime Phone:
Evening Phone:
Email Address:
Birthdate:
Marital Status:
Children's Names and Ages:
Childcare Requested: YesNo
Occupation:
Do You Believe in God? YesNoNot Sure
Describe yourself spiritually:
What are you expecting to gain from this study?:
Identify any fears that you have regarding this study:
List any other information about yourself you would like to share. ie; hobbies:
Have you ever sought professional counseling, or therapy, for your abuse? YesNo
Briefly explain:
Clicking "Submit" sends the above information to us via e-mail You will receive a confirmation of receipt, via e-mail, with further information / instruction.


If you have any problems submitting your personal profile with this page, please send the above information to Michele Tyson's email.
Or to: First Assembly of God, Journey To Total Freedom, 4501 Burrow Drive, North Little Rock, AR 72116

At this time, we only offer classes at First Assembly in North Little Rock, AR. However, if you are interested in a free online class, please contact us or let us know by taking the poll. If we recieve enough interest, an online class may be offered.
Would you be interested in a free online class?
Yes, Very interested!
Maybe.
Probably Not.
Definately Not!
  
Free polls from Pollhost.com