Heal the Valley Registration Form

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MARCH TO HEAL THE VALLEY October 7 – 11, 2013     Registration Form

CHAM Deliverance Ministry

Name(s) ______________________________________________________________________________

Address ______________________________________________________________________________

City ____________________________________ State ____________________

Zip code ____________

Phone number _________________________

Email __________________________________________

Gender ___________________

Languages spoken ___________________________________________

Group Organization______________________________________________________

Days You Will Participate:

Mon Oct 7 _____ Tues Oct 8 _____ Wed Oct 9 _____ Thurs Oct 10 _____  

Overnights: 

Mon. Oct 7 _____ Tues Oct 8 _____ Wed Oct 9 _____ Thurs Oct 10 _____

Can you identify financial or other contributors? _____________________________________________

Names and ages of children participating  __________________________________________________

Any special medical conditions or dietary needs _____________________________________________

RULES: I agree to avoid use of any drugs, alcohol, or violence during the March to Heal the Valley and to respect the leadership of CHAM and the co-sponsors and hosts of the march.

 Signature of Participant _______________________________________   Date_____________

Please return this form to: CHAM Deliverance Ministry, 304 N Sixth St, San Jose, CA 95112

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