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kcmember survey

MEMBER INFORMATION SURVEY
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  Member Number Please enter valid data.
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  Nickname Please enter valid data.
  
  Check if New Address
  
  Street Address REQUIRED Maximum 50 characters Please fill out this field. Please enter valid data.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Email REQUIRED Please fill out this field. Please enter an email address.
  
  Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Marital Status
  
  Spouse Name / DOB Please enter valid data.
  
  Preferred Method of receiving Annual Dues Statement
  
  What Activity are you interest in? Haunted Castle Free Throw Contest Mass Traffic Control Parish Breakfast Vincentfest Other
  
  List Other Activities Interested in
  
  Are you a registered member of St Vincent Parish
  
  Have you taken the Diocese Safe Environment Training and Background check? Required for activities involving children.
  
  Would you be in favor of receiving electronic copy of Membership Card
  
  Suggestions
  
  Submit
  
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