Please write legibly and fax to 815-301-9737.
Name: ____________________________________________________
Address: ___________________________________________________
Home Phone: ____________________ Work: _____________________
Cell: _________________________ Fax: ____________________
Email: ________________________ Age: ___ In Relationship? Y or N ___
Why are you joining The Get Real Men's Group? (What's happening?)
What is your primary goal in attending? (Where do you want to go?)
What do you feel you have to contribute to the other men who attend The Men's Group?
Anything else I should know?