Anchor Registration - January 10, 2012

REGISTRANT INFORMATION:

Name 

Address 

City, State, Zip 

Home Phone 

Cell Phone 

Email 

For placement assistance:

I am  married   single

Age:  20-29   30-39   40-49   50-59   60+

If you have children, please indicate how many and the age group:

How many children?

Check all that apply:
Infant/Toddler
Preschool
Elementary School
Middle School
High School
College
Grown

Do you have a church home?
Yes        No

What church are you attending?  

How did you hear about the ANCHOR?

Is this your first year in the ANCHOR, or are you returning?  First time     Returning

Childcare and a Homeschool Class is available for Tuesday & Wednesday morning studies.

Please list each child needing childcare:

Name    Date of Birth  

Name    Date of Birth  

Name     Date of Birth  

Name    Date of Birth 

Name    Date of Birth  

Name     Date of Birth 

I am interested in the following ANCHOR Bible Study for January 2012:

Tuesday morning (10:00 a.m. - 12 noon)
Tuesday evening (7:00 p.m., off campus)
Wednesday morning (10:00 a.m. - 12 noon)
CCC staff women (Wednesdays at 11:30 a.m.)
Satellite group
>> If interested in a satellite group, please specify day & time :

Is there anything else you would like us to consider as we prayerfully connect you to a small group?  Please let us know in the box below.

Registration fee:
$30 one-time fee
**If you need financial assistance, please see options below.

Childcare fees (these one-time fees cover the whole year):
$10 for 1st child
$5 each for 2nd/3rd child
4th child is free

Payment Options:
I'd like to request a scholarship.
I'd like to pay for another woman to be able to attend the ANCHOR. (Option to donate towards scholarships will be available on the next page, after you submit this form.)