Please Print Clearly and sign the bottom Birth ______/ ______ ...
Please Print Clearly and sign the bottom
Birth _______/ _______/ _________ Month Day Year
First Name__________________________Last Name ___________________________ Address _________________________________________________________________ City State Zip Male
Female
Group Name _______________________________________
Church Name___________________________School/Employer ___________________ Phone __________________________________________________________________ Please include Area Code Home Work Mobile 671 Jackson Spring Rd Ozark, MO 65721 417-443-6600
5(/($6($*5((0(17 , WKH *XHVW DQG SDUHQW RU OHJDO JXDUGLDQ RQ KLVKHU EHKDOI LI *XHVW LV XQGHU DJH NQRZDQGXQGHUVWDQGWKDWDFWLYLWLHVDW'RHQQLJ6SRUW6ZLQJVDQG2]DUN 3DLQWEDOOPD\EHKD]DUGRXVSDUWLFLSDQWVDQGRUREVHUYHUV DQGWKDWSHUVRQVLQKLE LWHGE\GUXJVRUDOFRKROSHUVRQVZLWKKHDUWEDFNRUOHJSUREOHPVDQGSUHJQDQW ZRPHQVKRXOGQRWSDUWLFLSDWHLQVXFKDFWLYLWLHV*XHVWKDVQRWFRQVXPHGGUXJVRU DOFRKROLFEHYHUDJHVZKLFKVHULRXVO\LQKLELW*XHVW¶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¶VSDUHQWRUOHJDOJXDUGLDQ,I JXHVW LV XQGHU 81&21',7,21$//
Birth _______/ _______/ _________ Month Day Year
First Name__________________________Last Name ___________________________ Address _________________________________________________________________ City State Zip Male
Female
Group Name _______________________________________
Church Name___________________________School/Employer ___________________ Phone __________________________________________________________________ Please include Area Code Home Work Mobile 671 Jackson Spring Rd Ozark, MO 65721 417-443-6600
5(/($6($*5((0(17 , WKH *XHVW DQG SDUHQW RU OHJDO JXDUGLDQ RQ KLVKHU EHKDOI LI *XHVW LV XQGHU DJH NQRZDQGXQGHUVWDQGWKDWDFWLYLWLHVDW'RHQQLJ6SRUW6ZLQJVDQG2]DUN 3DLQWEDOOPD\EHKD]DUGRXVSDUWLFLSDQWVDQGRUREVHUYHUV DQGWKDWSHUVRQVLQKLE LWHGE\GUXJVRUDOFRKROSHUVRQVZLWKKHDUWEDFNRUOHJSUREOHPVDQGSUHJQDQW ZRPHQVKRXOGQRWSDUWLFLSDWHLQVXFKDFWLYLWLHV*XHVWKDVQRWFRQVXPHGGUXJVRU DOFRKROLFEHYHUDJHVZKLFKVHULRXVO\LQKLELW*XHVW¶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¶VSDUHQWRUOHJDOJXDUGLDQ,I JXHVW LV XQGHU 81&21',7,21$//
