ONE MONTH TO LIVE REGISTRATION FORM

Thank you for taking time out of your busy schedule to register for One Month To Live Group Challenge. Please fill out the form below.


* Will you be participating in the One Month To Live Small Group Challenge?

* Would you like to be a facilitator of a small group?

* Full Name
* Address
* City
* State
* Zip Code
* Phone (Home)
* Phone (Cell)
* Email
* Are you a member of West Point?

Please select the group you would like to participate in:
Men All Ages Men All Ages
Men 50+ Men 50+
Men 26-40 Something Men 26-40 Something
Men 18-25 Men 18-25
Women All Ages Women All Ages
Women 50+ Women 50+
Women 26-40 Something Women 26-40 Something
Women 18-25 Women 18-25
Married Couples Married Couples
Singles Mixed Singles Mixed
Single Men Single Men
Single Women Single Women
College College

* Will your child/children attend One Month To Live for students?
If yes, which grade(s):
 


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184 Hartfield Rd. | Hattiesburg, Mississippi 39402 | (601) 271-2227 | (601) 271-2265 Fax