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FAITH IN ACTION! INC (FIA) Programs Registration Form
Please complete this form for ALL FIA PROGRAMS/PARTNERSHIP PROGRAMS
Email address *
FIA Programs (check all that apply) *
Required
Referral Source: How did you hear about us? *
Your answer
Child/Participant Name *
Your answer
Address *
Your answer
City/State/Zip Code *
Your answer
Telephone Number *
Your answer
Age *
Your answer
Birthdate: *
MM
/
DD
/
YYYY
Gender *
Race *
Grade *
Your answer
School *
Your answer
Participant Email *
Your answer
Parent/Guardian Name *
Your answer
Telephone/Address (if different from above) *
Your answer
Parent/Guardian Email *
Your answer
Emergency Contact Name and Phone Number *
Your answer
Relationship to Child *
Your answer
Any Special Needs or Interests? (Write Here)
Your answer
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