ENROLLMENT FORM

Please enroll me for my full commitment of the year long Spiritual Recovery Correspondence Course. PLEASE PRINT CAREFULLY.

First Name:______________________ Last Name:_____________________D.O.B._______________

Inmate #:________________ Unit Name, Bunk & ______________________
Other Identification

Name of Institution:________________________________________________________

P.O. Box:________________ Street Address:____________________________

City:_______________________ Zip Code:___________State:_____________

Country:____________

Contact Person:_____________________________________________
(Chaplain or person who can best help you receive our materials if you are not able to)

Do you have any restrictions, or special needs that we need to know about?
If so, please explain________________________________________________
________________________________________________________________

Do you speak another language?_____If so, what?_____________________

Will you be transferred to another unit or prison, or will your status change while taking this course?_____ If so, please explain___________________________
________________________________________________________________

Which of the following items are you able to receive and use?
Please Circle:
1. Audio Tapes 2. Video Tapes 3. Compact discs (CD's) 4. NONE of these

Do you have access to a library? Yes

Mail this to:

Miracles Prisoner Ministry
Correspondence Course
501 East Adams Street
Wisconsin Dells, WI 53965