Name *

First Name

Last Name

Phone

(###)

###

####

Age

18-24

25-29

30-39

40-49

50-64

65+

Checkbox

Single

Married

Divorced

Widowed

Which of these issues are most important to you? (Check the two most important)

Family relationships

Male roles and identity

Health

Service Projects

Vocational issues

Balancing family/work/other interests

Retirement

Spiritual life

When would be the best time to gather for fellowship with other men?

Early Morning

Noon

Evening

Weekend

Weekdays

What length of time could or would you be willing to commit to deal with these issues?

One weekend

Four to six weeks

Six months

One afternoon or morning

Three months

Indefinite