Free Indeed

Recovery Program Registration Form

First and Last Name

what is the reason for you attending our classes?

Email

Best cell Phone to call or text?

Can we text this phone?

Yes

No

Full Mailing Address to send mail to (not required if homeless or secret)

Are you currently attending another church?

Yes

No

Name of Church you regularly go to (if not, N/A)

Is this a required course per court order?

Yes

No

If you have a parole officer associated with this, please provide their contact information here:

Are you currently in any other Recovery Program?

Yes

No

If you are attending another program, please let us know which one(s):

Is there anything specific you would like us to pray for you about?

Our classes are Fridays at 11am-2pm starting July 10th 2026. Which date you will start attending our classes?

Month

Day

Year

Time

HoursMinutes

I am aware that Eagle River Baptist Church will not share my information to any third party, and it is only going to be used for the purposes of this program and church related matters, and not to solicit money. x________Signature

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