CHOSEN GENERATION EVANGELISTIC MINISTRY, Port Arthur, TX

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Name:

Full Address

Email:

Phone:

Date of Birth

Are you disabled?

Yes

Are you a veteran?

Are you pregnant?

How'd you hear about us?

1st Child's Name

1st Child's Age

1st Child's Grade

1st Child's Uniform Size

1st Child's Gender

2nd Child's Name

2nd Child's age

2nd Child's Grade

2nd Child's Uniform Size

2nd Child's Gender

Do you have more than 2 children?

Yes

I understand that there is a possibility that Chosen Generation Evangelistic Ministries drive recipients may be photographed during their experience to help promote the program. I grant permission to be photographed for this purpose.

Yes, I understand

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SUPPLYING THE FUTURE

REGISTRATION FORM

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CONTACT

chosengem.portarthur@gmail.com

P.O. Box 5232

Beaumont, TX 77726-5232

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