Thank you for your interest in the Our Whole Lives Evaluation and Promotion Project! Please provide the information requested below. The final selection of congregations and organizations will reflect a concern for diversity in denomination, geography, racial/ethnic composition, and other factors. The items on this form are especially designed for information from congregations. If you are expressing interest as a community organization or center rather than as a congregation, skip those items that seem not to apply and add any information that may help us better understand your work. If you have questions about anything in this booklet, please contact Melissa Lopez: e-mail lopezmelissa@me.com or call Christian Community at (800) 774–3360.

Church or Organization: Denominational affiliation if relevant: Street Address: City: State: <Choose One> Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip Code: Phone:

If your congregation or organization has a website, what is it's address?

Contact person at your congregation or organization about potential Our Whole Lives participation: Name Church position Phone E-mail

Congregational information: Average worship attendance: Number of congregation members in grades 7–9: Number of congregation members in grades 10–12:

Are you interested in participating in the Our Whole Lives evaluation? YesNo If yes, are you interested in the evaluation of Our Whole Lives for: Middle school youth (grades 7–9)? YesNo High school youth (grades 10–12)? YesNo Would you like us to send you additional copies of the booklet to be shared with others in your congregation? YesNo If so, how many?