Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Do you have a personal relationship with Jesus Christ? *

Yes

No

Not sure

Are you a member of Ren Church? *

Yes

No

Which best describes your attendance at Ren Church? *

Frequent

Sometimes

Seldom

Never

Which best describes your current financial situation *

Short term emergency

Short term problem

Long term problem

Are you willing to receive financial counseling? *

Yes

No

Are you currently employed? *

Yes

No

Full-time

Part-time

If married, is your spouse employed?

Yes

No

Full-time

Part-time