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The Rock Church & World Outreach Center




Breaking Free Youth Form






Last Name: First Name:DOB:
 
Suffix: Ethnicity:   
 
Name of Parent / Legal Guardian:   
 
Address: Apt #:
 
City: State: Zip:
 
Email: Phone: Gender:
 
Membership Status -
       Do you regularly attend the Rock Youth Service?:
 
Have you accepted Jesus as your Lord and Savior?
 
Why are you interested in Breaking Free 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?
 


*PLEASE NOTE THERE IS A $20.00 REGISTRATION FEE DUE AT CLASS ORIENTATION

*CLICK HERE TO DOWNLOAD A PARENTAL CONSENT FORM




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