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The Rock Church & World Outreach Center




Breaking Free Adult Form






Last Name:  First Name:  DOB: 
 
Suffix:  Ethnicity:    
 
Address:  Apt #: 
 
City:  State:  Zip: 
 
Email:  Phone:  Gender: 
 
Marital
Status:
  Membership
Status:
 
 
Child Care Fees:    1 - 2 children $15.00    3+ children $30.00 (per quarter)
(Please list how many children ages 0 - 6th grade that would require child care)
Number of
Children:
    
 
Have you accepted Jesus as your Lord and Savior?
 
Why are you interested in Breaking Free?
 
(If Referred by Pastor, please enter name)
 
(If Other, briefly describe)
 
 
Have you taken Breaking Free before?
 
How many times?
 
Can you attend the Breaking Free Orientation at The
       Rock Church (A Saturday afternoon class)?
 
Are you willing to commit to the class for eight weeks?
 
Are you willing to pray and journal daily?
 
Are you willing to call a mentor once a week?
 


*DUE AT ORIERNTATION $25.00 MEMBER/REGULAR ATTENDEE - $50.00 NON-MEMBER

*CHILD CARE FEES DUE AT ORIENTATION OR THE EVENING OF THE FIRST CLASS




Phone: 909-825-8887
Email: .(JavaScript must be enabled to view this email address)