First Name       Last Name 

Address: 

City:    State:    Zip 

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Go to our homepage and look for the link on the left that says "Youth Ministry E-zines" to see an example)

E-mail Address: 

Home Phone (include area code):    Work Phone (include area code)

Name of institution: 

Position with this Group: 

Are you the Key Contact for this group?   Yes       No

Responsibilities (check all that apply)

Junior High         Young Adults          Boy Scouts          Other (describe below)
Senior High        Athletics               Girl Scouts