MOM New Customer Registration Form

College Care Package:

Sponsored by: Ministry of Mercy - St. John's Lutheran Church, LCMS; Kimball, MN
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail
What year of college are you in?*
Other*
Are you alergic to any foods?
Should be Empty:

College Care Package: