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* 1. Marital Status

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* 2. Age Group

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* 3. Children?

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* 4. Number of Children

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* 5. Age group of children? (Check all that apply)

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* 6. I would be available to meet on the following days. (Check all that apply)

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* 7. I would be willing to facilitate a small group study

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* 8. My home is available for a small group study meeting place.

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* 9. What is your name?

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* 10. Contact Number

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