Encourage HER Class Registration
Weekly discipleship classes to help every woman live free from life-controlling struggles.
Your Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email Address
example@example.com
Why are you interested in this class? (Mark all that apply.)
*
I am an addict and I need help.
I am a former addict and want to stay free.
I have a friend/family member that is an addict.
I currently live with an addict and need a support group.
I want to help others find freedom from addiction.
Other
If you are currently struggling with addiction, what are you struggling with? (Mark all that apply)
Alcohol
Methamphetamines
Marijuana
Prescription Pills
Cocaine
Heroin
Abusing Others/Self
Anorexia/Bulimia
Pornography/Sex
Same-sex Attraction
Gambling
Stealing
Child care will be provided for children ages 5 to 12. Will you be bringing any children with you to this class?
*
Yes
No
If you selected YES to child care, how many children will you be bringing?
Have you participated in any other "overcoming addiction" type programs/classes in the past?
*
Please Select
Yes, as an addict.
Yes, as a support person for someone else.
No
Do you believe in God?
*
Please Select
Yes
No
Not Sure
Have you ever committed your life to Jesus Christ?
*
Please Select
Yes
No
Uncertain
Are you currently involved in a church or religion?
*
Please Select
Yes, regularly attend.
Somewhat, occasionally participate.
No
Briefly tell us what you hope to gain by taking this class?
0/200
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