Basic Training for Men class registration background information

Name

Phone number (best number to reach you)

County of residence

Champaign

Clark

Greene

Other

How would you describe your marital status? (check as many as apply)

If married, for how many years?

Number of children under 18 living with you:

Expectant parents?

Yes

No

Have you or your partner attended any previous class sponsored by Marriage Resource Center?

Yes

No

How did you hear about us?

IMPORTANT!
Please submit form and proceed as instructed to select class date(s) and enter contact information

Indicates Response Required

Single	Dating	Engaged	Cohabiting
Married	Separated	Divorced	Step-family