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* 1. Your name:

* 2. Acadiana Area Theresians will not share this information with anyone.

What day of the week is good for you to meet?

* 4. To which church/parish do you belong?

* 5. How many miles are you willing to travel to meet with your community once a month?

* 6. Do you have your own reliable transportation?

* 7. Please type your email address in the box below so we may contact you. Your email address will be kept confidential.

* 8. List alternate ways in which we may contact you.

* 9. Questions and/or comments: