COURSE ENROLEMENT: - SELECT ONE -StudentGroups Only ENROLLMENT METHOD: - SELECT ONE -Groups Only ($50/mo.)Student ($100/mo.)Student ($270/phase)Student ($765/course)
Last Name First Name M.I.
Age D.O.B. Soc. Sec. # Rel. Status SingleMarriedDivorcedSeparatedIn A Relationship
Street Address City State Zip
Contact #1 Type CellHomeWork Contact #2 Type CellHomeWork
How and when did you first find out about "Daughters of Naomi?"
Can you describe how you came to be a Christian?
What background do you have in the church? (ie: denomination or belief practiced? Family members that are religious? Positive\Negative experience with church)
Describe any experience(s) with spirituality outside the church institution? (ie: fortune telling, horoscopes, ouija boards, etc.)
What do you hope to accomplish by enrollng in Daughters of Naomi?
I, by my signature, attest to the validity of the information contained in this document. I understand, that any discrepancies or information withheld brought to the attention of Daughters of Naomi, may result in my not being accepted into the program.
TELL US YOUR STORY
Family background and childhood experiences from birth to 6th grade: (focus on times you moved, change in family dynamics, any memorable event)
Family dynamics and social experiences from age 12 through 19 (focus on major events)
Family dynamics and social experiences as a young adult to present
FULL DISCLOSURE STATEMENT:
LIST ALL YOUR CHILDREN: (If you don't know the father, if you gave a child up for adoption...say so. Give an account for every live birth.)
Name Age Father Custodial Parent
Mark Clearly any of the following issues you have or are experiencing. Give brief description.
LIST HIGHEST LEVEL OF EDUCATION ATTAINED \ Degrees, Certifications or Special Occupational Skills
School Attended Certification\Degree Date\Level of Completion
LIST 2 PEOPLE WHO CAN VALIDATE YOUR DEDICATION TO THIS DECISION TO CHANGE YOUR LIFE
Name Contact # Relationship
If Recommended By a Graduate Advisor, Please Choose Which One Here Amy SvenssonTammy Bolt WerthemLori PomnitzCaroline ArnoldErica ChalifouxToni Stelmack CruzNichole Scherer
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