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Note: Pre-registration is required - print this form, fill it in and send it:
Who Am I Now?
c/o Family Life Office
3214 North 60th Street
Omaha, NE 68104
(402) 551-9003
(Please use one for each child)
For session beginning: ____________________________________________
Child's name: _____________________________________________________
Age: __________ Grade: __________
Child lives with: _________________________________________________
Specify relationship: _____________________________________________
Address: __________________________________________________________
City/Zip: _________________________________________________________
Is you child in counseling? Yes _____ No _____
Please circle and date which applies to parents of child:
Separated Date: ______________ Divorced Date: __________________
Widowed Date: ________________ Remarried Date: _________________
What you like to see your child gain from attending the sessions?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Emergency Information:
Name: ______________________________________________________________
Relationship: ______________________________________________________
Phone: _____________________________________________________________
Parent or designated person must come to the small group room to pick up each child.
Suggested donation is $10 for all six sessions for one child or $15 for two or more children. No one is turned away because of inability to pay.
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