Name:

Address:

 

City, State, Zip: 

E-mail:

 

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please enter your e-mail again here: 

Phone:

 

I am / We are:  Single Married

 

Approximate age(s) - select all that apply:

 18 - 29

 30 - 39

 40 - 49

 50 - 59

 60+

 

Children living at home?  Yes No

 

If Yes, list their names and ages: 

 

Hobbies / Special Interests: 

 

I usually attend the following service:  8:45 am Traditional 11:00 am Traditional 11:00 am First Place

I/we are looking for the following type of group:  Any Group Women only Men only Couples Mixed

 

When would you prefer to meet?  Weekday mornings Weekday afternoons Weekday evenings Weekends Anytime

If there is anything else we should know about your preference, please include a message in the box below.