Prefix First Name MI Last Name Sufix (Lay or (C)lergy .
Mr. Mrs. Miss. Ms. Dr. Rev Hon. Lay Clergy
Address Name Tag F Name
City State Zip
Address that Inmates will use to mail letter (can not be your home address)
Not Home City Not Home St Not Home Zip
Daytime Phone Home Phone Cell Email
Gender Date of Birth DL Number SS Number TDCJ Trained
No Yes
I attended Cirsillo Emmaus Other Tres Dias Via de C Number Year at (location)
I am active in a Reunion Group in your 4th Day community No Yes
Are you related to or know anyone in Hughes (other that through Kairos) No Yes
Are you on any visitation at Bartlett State Jail? No Yes
If yes Inmate's Name and Number
Your relationship to inmate Son friend husband nephew cousin fiance other
Your name as you sign it agreeing that all the above is true Date
Your Church Denomination
Church Address
Church City St Zip
Pastor's Name Church phone
