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HSLHS Registration Form
Please complete the following registration information.
13
Questions
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1
Confirm Your Participation with:
*
This field is required.
Email
Phone Number
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2
Name
*
This field is required.
First Name
Last Name
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3
Email
*
This field is required.
example@example.com
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4
Phone Number
*
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Area Code
Phone Number
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5
Country
*
This field is required.
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6
State
*
This field is required.
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7
City
*
This field is required.
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8
Do you require healing?
*
This field is required.
YES
NO
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9
If you do require healing, please share details of your condition. (ie. Name of condition, symptoms, diagnosis, how long you've been in this condition, etc.)
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10
Share the Healing Streams with your friends?
*
This field is required.
YES
NO
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11
Do you want to be a Translator for the program?
*
This field is required.
YES
NO
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12
How did you hear about the Healing Streams Live Healing Service?
*
This field is required.
Church
Family
Flyer
Friend
Social Media
Other
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13
Please provide the name of the person that invited you to register?
*
This field is required.
Please list the First and Last Name (if known) OR Unknown
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