Single and Parenting Registration

Single & Parenting Registration

By submitting this form I agree that I understand confidentiality is mandatory in the support group and that anything said in the group is to stay in the group. I understand Single & Parenting is not counseling, but a peer support group led by volunteers. I also understand the volunteers and leaders of this program have an obligation to report any disclosure of intent to harm oneself or others to the pastors at Christ Baptist Church, my church, or to any other appropriate agency. Note that a $20 registration fee is required on your first night but we can cover this via a scholarship fund if required.
  • Please enter an e-mail address if you have one. We will use this as a main form of communication with you. We promise your e-mail address will not be sold or shared with anybody. If you do not have e-mail then we will communicate directly with you via your phone number.
  • Please enter your primary phone at which you can be contacted.
  • Please enter an alternate contact phone number for you. It could be your home, cell or work number.
  • Enter the name of the person to be contacted in the case of an emergency.
  • Enter the name of the phone number for the person you've listed as your emergency contact.
  • Enter the name of your home church and your Pastor's name if you have one. If you don't have one just enter "None."
  • This is just required so that we can plan accordingly for your children to attend. Thanks.