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Life Together
Let's do life together. Let's make an appointment.We will go as far as you want to go, as fast you want to go, or just grab coffee.
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Email *
Today's Date *
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Name (First & Last) *
Date of Birth *
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Contact Phone #
Street Address
City, Zip *
Best Ways to Contact You: *
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How did you hear about us? *
Household Members (name and birth dates): *
Mutual Agreement

The information provided on this form is true to the best of my knowledge. I authorize Victory Mission to verify this information and talk with me about my situation. I agree to comply with the rules and procedures of Victory Mission, written or stated, and understand that failure to follow rules and procedures may result in loss of privileges to benefit from some or all of Victory Mission’s services.

I understand that the information that I provide may be released to third parties, including other social service providers, churches, or agencies that may provide services to myself and my household. I agree with these statements and release Victory Mission from any liability for releasing my client information.
In regard to the statement above *
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