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Name:         Birthdate: 19

Marital Status:
single
engaged            wedding date:
married               anniversary:
divorced
widowed

Spouse's Name (if applicable):    Birthdate:19

Street Address:     City:
Zip:
Phone:
E-mail:

What type of group would you like?
singles
married couples
college:
       fresh.     soph.       jr.      sr.
        college campus:

What day(s) of the week do you prefer to meet?
sun.    mon.        tues.         wed.         thurs.    flexible

Do you have children?     yes     no    how many?
        Ages:    preschool    elementary    middle    high    college    empty nest

Do you have comments? Questions? Take a moment to let us know.

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