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first: |
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maiden: |
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married: |
____________________________________ |
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Address: |
_____________________________________ |
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_____________________________________ |
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Phone: |
__________________________ |
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Email (optional): ________________________________ |
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Religious name
in community: _____________________________________ |
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Entrance
year: ___________________
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Name as you would like it to appear on nametag: |
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_________________________________________ |
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Yes, I’d like my contact information to be included
in a directory of participants and invitees to the
Back to Baden Gathering. |
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| Total registration/contribution enclosed: $__________
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Return this form & payment to:
CSJ
GATHERING 2003
1020 State St.
Baden,
Pa. 15005
by
APRIL 10, 2003
Back
to Baden Gathering
|
