First Name: __________________________ Last Name: ______________________________

Birth date : ______/______/______  Age:_____   Check One: ____ Male  ____ Female
             Month       Day        Year 

Street Address: ________________________________________________________________

City:	_________________________ State: ___________________ Zip Code: _________

Country: _________________________  Your E-mail Address: _______________________

Please print your Return Mailing address:(As it appears on envelope)
________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Special comments or requests:
________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Name Of contact person and their title 
at the congregation where you worship:__________________________________________

________________________________________________________________________________

________________________________________________________________________________

E-mail address of contact person where you worship:_____________________________

Name and address of
Congregation Where you worship:_________________________________________________

________________________________________________________________________________

________________________________________________________________________________

E-Mail address of Congregation where you worship:_______________________________

Check your FIVE favorite Interests:

(Mail to:   ChrisCross  LaGrange Church of Christ   P.O. Box 1254, LaGrange, Texas   78945 (979) 968-5676)