1: Name(s)

2: Address

Phone:

4: Email

Age: * Choose only one of the following 18-30 31-40 41-50 51-65 66+

6: Group Preferences (we are not always able to accommodate all group preferences) Day of the week: Check any that apply   Sunday Monday Tuesday Wednesday Thursday No Preference

7: Group Preference: Group Make Up Check any that apply   people my own age a wide variety of ages no preference

8: I would like to be contacted during the Check any that apply   Day Evening Weekend

9: By Check any that apply   Mail Phone Email