PARENTS AND FRIENDS OF EX-GAYS & GAYS (PFOX)
Application to Start a PFOX Local GroupSend this completed application to:
PFOX, P O Box 510, Reedville VA 22539, phone 804-453-4737, ex-gays@earthlink.net
Please answer all of the following questions and submit a resume, if available:
Nearest city and state of affiliation: _____________________________________Designated Group Director:
Name: ____________________________ Date of birth: _______________________
Address: _______________________________________________________________
City, State, Zip: __________________________________________________________
Day Phone: _________________________ Evening Phone: _____________________
Occupation: _____________________ Name of Employer: _____________________
Please list two references who have known you for at least three (3) years, including your pastor or deacon, if possible:
1) Name: ____________________________ Occupation: ______________________
Address: _______________________________________________________________
City, State, Zip: __________________________________________________________
Day Phone: _________________________ Evening Phone: ______________________
2) Name: ____________________________ Occupation: _____________________
Address: _______________________________________________________________
City, State, Zip: __________________________________________________________
Day Phone: _________________________ Evening Phone: _____________________
Group Co-Director (if any):
Name: ____________________________ Date of birth: _______________________
Address: _______________________________________________________________
City, State, Zip: __________________________________________________________
Day Phone: _________________________ Evening Phone: _____________________
Occupation: _____________________ Name of Employer: _____________________
Co-Director’s references, including a clergy member, if possible--
1) Name: ____________________________ Occupation: ______________________
Address: _______________________________________________________________
City, State, Zip: __________________________________________________________
Day Phone: _________________________ Evening Phone: ______________________
2) Name: ____________________________ Occupation: _____________________
Address: _______________________________________________________________
City, State, Zip: __________________________________________________________
Day Phone: _________________________ Evening Phone: ______________________
Group Information:
Meeting Location: ________________________________ (home, church, business, etc.)
Meeting Day and Time: _____________________ Frequency: ____________________
If available, separate phone number for referrals to your group: ________________________________
E-mail Address: _____________________________ (PFOX will publish your group's email address and phone number on the PFOX website so you can receive referrals directly.)
If you represent an already existing group, ministry or organization with its own name and status, you may apply as a PFOX ally:
Yes _________ (Enclose your group‘s literature). Group‘s name: _________________
Please answer each question:
How did you find out about PFOX?
Why are you interested in starting a local PFOX group?
How can PFOX assist your newly formed group?
What issues concern you? How do you think PFOX can address those issues?
Are you or have you been a member of another ex-gay or gay group or organization? If so, please tell us about it.
Director’s Signature: _____________________ Date: _________________________
Co-Director’s Signature (if any): ___________________ Date: ___________________