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Study:

First Name:

Last Name:

Street:

City:

State: 

Country: 

Zip:

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2 Phone:

Email:

2 Email:

DOB (mm/dd/yy):

Height:

Current Weight:

Desired Weight:

Do you have Excel:

Do you have MS Works:

Do you have Power Point:

Do you have MS Publisher:

Do you have MS Word:

Are you a Group Leader:

Are you at your goal weight:

Tell me a little about yourself:

Are You Enquiring about the program only:

What are your training needs

and topics of interest:

Comments or Questions:

Are you interested in hosting a workshop:

Check this box and enter the information below if you are participating and/or leading a local First Place Group.

Local Group Information

Yes, I am part of a local First Place Group.

Church Name or Home Group meeting is held:

 Location/Venue where meeting is held:

First Place Class Day and Time:

Session Start Date:

Session End Date

What Bible Study will you be doing next:

Group Leader (s):

Leader (s) Phone Number and Email: