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On-Line Registration Form

You can use your mouse and the regular keys BUT DO NOT press ENTER until finished

Date: Envelope # :

Family Last Name     :

First Name (Husband):

First Name (Wife)      :

Street Address

Apt. No.Street City Postal Code

Phone Number(s)

Home phone #: Cell Phone #:
e-mail address;:
repeat e-mail address;:

Children(living at home)

Child's Name
Child 1: sex Date of Birth: Month Day : Year :
Child 2: sex Date of Birth: Month Day : Year :
Child 3: sex Date of Birth: Month Day : Year :
Child 4: sex Date of Birth: Month Day : Year :
Child 5: sex Date of Birth: Month Day : Year :

Comments (if you wish):
COMMENTS/QUESTIONS: