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Name (First & Last) *
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Date of Birth *
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How did you hear about us? *
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Tell Us About Your Household Status *
Please tell us a little bit about the situation you are facing right now. *
Tell Us How You're Feeling *
Which of these statements can you relate to? Select all that apply: *
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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 *
And finally, how can we pray for you?
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