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Lifelong Learning

YTM January Retreat Registration Form

2014 YTM January Retreat: January 3-4, 2014

Please check one:

Youth Adult Mentor Counselor Vocation Partner

First Name

Last Name

Street Address 1

Street Address 2

City

State

Zip Code

Phone Number - Home

Phone Number - Mobile

Email Address

Emergency Contact Person

Relationship

Emergency Contact Phone

Parish Name & Location

YTM Parish/School Team Members: