Each participating and mentor couple must complete and sign a conference registration form

Download Registration Form (Word Format)
Or fill out the form below and submit.

His Name:   Date of Birth
Her Name:   Date of Birth
Address:  

State  Zip
Phone: email:
Date of Marriage:
Number and ages of children: 
If you are a mentor couple, please skip to Part II.
Part I
Have you been to marital counseling?   Yes, No   If so, for how long? 
Name of Church:    Denomination: 
Are You Affiliated with an Exodus Ministry? Y /N
If so, with which ministry are you affiliated? 
Have you ever attended an Exodus Conference?  Y /N 
If so, please list the conference years: 
Have you ever attended a “Steadfast” conference? Y /N
If so, please list the conference years: 
Which one of you struggles with homosexuality? 
Please describe briefly how homosexuality has impacted your marriage: 

Please describe briefly what you hope to receive from this conference: 
Part II (Mentor Couples Only)
Name of Church:    Denomination: 
Are You Affiliated with an Exodus Ministry? Y /N
If so, with which ministry are you affiliated? 
Have you ever attended an Exodus Conference?  Y /N  
If so, please list the conference years: 
Please describe your relationship with the couple who invited you to this conference:

Please describe briefly what you hope to receive from this conference: 

Part III (all participants)
Name of emergency contact:
Phone Number of emergency contact:
Do either of you have any physical limitations or special needs?  Y /N
If so, please describe: 

The CPM Marriages and Mentors Conference will be providing all meals during the course of the weekend.  If you have special dietary needs or limitations, please describe them fully below, and we will do our best to meet them:

If there is any other information of which you believe we should be aware, please describe it below:

Signature Date
Signature Date