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Hands Up Outreach (CWJC/CMJC)
Student Registration Form
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* Indicates required question
Date
*
MM
/
DD
/
YYYY
First Name
*
Your answer
Last Name
*
Your answer
Birth Date
*
MM
/
DD
/
YYYY
Address Include City, State and Zip Code
*
Your answer
Telephone
*
Your answer
Email
*
Your answer
Gender
*
Male
Female
Do You Attend Church
*
Yes
No
Name of Church You Attend
Your answer
Check Areas of Interest
*
High School Equivalency (GED)
English As A Second Language (ESL)
Required
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