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Friday 9/27 6-9p, Saturday 9/28 9a-4p, and Friday 10/25 6-9p
Friday 9/27 through 10/25/204 3 sessions

Centerpointe Christian Church
1100 Center Road, Venice, FL 34292

English Childcare not available

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Husband First Name
Last Name

Date of Birth

Cell Phone #Format: 555-456-7890
Email Address
Street Address
City
State
Zip
Gender

Wife First Name
Last Name

Date of Birth

Cell Phone #Format: 555-456-7890
Email Address

Mailing Address same as Husband

Gender

Who is filling out this form ?

Husband

Wife

I have read and agree with the terms described in the document.