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* 1. Name

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* 2. Phone Number

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* 3. Email

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* 4. Spouse will attend group with me

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* 5. My (OUR) age group is

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* 6. I would prefer to be with people of the following age/stage in life (check all that apply)

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* 7. Names and Ages of at home children:

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* 8. My Next Steps (check all that apply):

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* 9. My/Our free nights in a week are

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* 10. What did you appreciate about this presentation?

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* 11. What could we do differently to make this information more effective?

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* 12. My/our children will need need to:

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