1.In which of the following services would you have an interest?

Nutrition and vegetarian cooking classes

Weight control seminar

Visiting and praying for the sick

Care for the elderly

Clothing and food assistance

Ministry in crisis (bereavement, grief, midlife, other)

Marriage enrichment seminar

Parenting skills for children and adolescents

Youth and peer pressure management

Mentoring and counseling program for youth

Substance abuse counseling

Classes on the meaning of life/my relationship with God

2.In your own words, identify the three most urgent needs in your neighborhood.

3.If the service and activities you indicated were offered in your neighborhood, would you participate?

Yes

No

4.Please indicate any area you would be interested in helping to provide:

Distributing care packages to my neighborhood

Distributing food to my community

Distributing clothing

5.Please indicate any additional area you would be interested in helping to provide:

6.Name and Contact Information (Optional - May apply N/A)