Women’s Group Registration Form 2018-2019 St. Francis of Assisi Women's Group This year we will study THE PURPOSE DRIVEN LIFE: WHAT ON EARTH AM I HERE FOR, based on the best-selling book by Rick Warren. The book and study guide may be purchased through Christianbook.com. We will be showing the videos during our meetings and discussing both the guide and the book. We will have our first, introductory meeting on October 4th in the Parish Center Dining Facility from 9:15 - 10:15 a.m. Everyone is asked to register and pay $20 to join the group for a year, and an additional $20 covers childcare for all of your children during our meetings. Please complete this form to share information about you and your children in childcare, if applicable. Meeting dates are scheduled for October 4th, 18th; November 1st, 16th; December 6th, 20th; January 3rd, 17th; February 7th, 21st; March 7th, 21st; April 4th, 18th; May 2nd, 16th. Payment may be made by cash or check at your first meeting. Name* First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone*Email* BirthdayMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Have you attended a study before?YesNoDo you participate in a church? (not required by group)YesNoHow do you hope to benefit from your participation?Complete next section only if you desire childcare during our meetings.Please list names and ages of all children participating in our childcare.Child's NameChild's AgeChild's Birthday Mother's Name (if you are not the mother of the child(ren) First Last Mother's Cell Number (if different from above)Father's Name (if applicable) First Last Father's Cell NumberPlease list two people whom you give permission to pick up your child(ren) in case of emergency.NameCell PhoneRelationship to Child Child's Doctor's NameChild's Doctor's Phone NumberHealth Insurance Name, Policy Number, Insured's Name and BirthdateDo you give your permission for your child to be treated if there is a medical emergency?YesNoIs your child toilet trained?What are your child's favorite toys, songs, activities, and/or games?Please provide details if your child has allergies or any special needs.Is there any other information you'd like the childcare providers to know?