Registration

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Address

City, State, Zip Code

Phone Number:

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Head(s) of Household (Name/Birth Date)

Other Adults (Name and Birth Date)

Children Under 18 (Name and Birth Date )

Would you like to receive donation envelopes?

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No

Are you interested in making my weekly contribution via automatic bank withdrawal?

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Not at the moment, but I would like more information.

Primary language spoken at home:

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If your primary language spoken at home is not listed above, please indicate here: