Defining Moments Registration
Full Name: *
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Preferred Name:
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Birthday: *
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Gender: *
Permanent Mailing Address: *
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T-Shirt Size: medium *
School Mailing Address (if applicable):
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Email: *
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Cell Phone: *
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May we have permission to contact you with information about Defining Moments? *
Name of your home church:
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City/District of your home church:
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Pastor of your home church:
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Leadership positions you hold at church:
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Will you be enrolled in school in Fall 2017 *
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