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Church Name:
Church Address:
Church Address 2:
City:
State:
Postal Code:
Phone #:
Minister or Contact Name:
Email Address:
Cost Per Person:
Total Number Registering:
Total Amount Due:
Check #:

Make checks payable to: Hot Hearts - Texarkana

Mail to:

Kevin Myers, Registration Chairman
P.O. Box 369 - Texarkana, TX - 75504