Register a Recovery Group

Please fill out the following form completely. All fields (except cell phone and skills descriptions) are required.

Group Leader Contact Information
First Name:		Last Name:
Daytime Phone:		Cell Phone:
E-mail Address:
Name of Church:		Association:

Desired Place of Service (first choice)

Port Sulphur

New Orleans

Plaquemines Parish

Desired Place of Service (second choice)

Port Sulphur

New Orleans

Plaquemines Parish

Preferred Dates of Service
(not including travel days)

Number of Team Members

1-5	6-10	11-15	16-20
21-25	26-30	more than 30

Number of Team Members 21 and older:

Please write a brief description of any skills that
certain members of your team possess which are
related to the work being done at your selected site: