Community Connect Form
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Total # of persons in your household
*
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Next
Do you have any children ages 0-12 in your household?
*
Yes
No
If so, how many?
Please Select
1
2
3
4
5
6
7
Age of Child #1
Age of Child #2
Age of Child #3
Age of Child #4
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Next
Do you have any youth ages 13-18 in your household?
*
Yes
No
If so, how many?
Please Select
1
2
3
4
5
6
7
Age of Youth #1
Age of Youth #2
Age of Youth #3
Age of Youth #4
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Next
Do you have a Bible in your home?
Yes
No
Would you like a FREE Bible?
Yes
No
Would you like to understand your Bible better?
Yes
No
Back
Next
Please select all areas you are interested in or would like more information about.
Children's outreach programs
Youth outreach programs
Women's outreach programs
Men's outreach programs
Healthy lifestyle programs
Community Garden
Food Pantry
How did you hear about this even?
Friend or family
Facebook event
Radio
Newspaper
Other
Email notification?
Yes
No
Submit
Should be Empty: