Date of Birth *

MM

DD

YYYY

Cell Phone for Texts and Calls *

(###)

###

####

Home Phone

(###)

###

####

Work Phone

(###)

###

####

Gender *

Male

Female

Race *

American Indian or Alaska Native

Asian

Black or African American

Hispanic/Latino

Native Hawaiian or Other Pacific Islander

Two of More Races

White

Rather Not Say

Denomination *

Catholic

Protestant

Christian but Nondenominational

I have NEVER served on a Kairos Team

True (never served)

False (have served)

Dept of Corrections Trained? *

Yes

No

Attended Emmaus Walk, Cursillo, etc.

Yes

No

Participaton in Reunion Group?

Yes

No

Attended a Kairos Weekend *

Yes, as a Volunteer

Yes, as a Prisoner

No

Ex Offender *

Yes

No

Currently on Parole *

Yes

No

Are you on the Visitation List for Any Prisoner in this Prison? *

Yes

No

I agree with the above Statement of Faith *

Yes

By submitting this form, I certify that the information provided on this Application is complete and true to the best of my knowledge. * *

Yes