Group Leader Registration
*First Name:   
*Last Name:   
Gender:
Date of Birth:
Address 1:
Address 2:
City:
State:
Zip:
Home Phone: - -
Work Phone: - -
Cell Phone: - -
*Email:     
Country:
Type:
T-Shirt Size:
Dietary Needs:
   
Group Information
   
*Group Name:   
Parish:  
Parish Address:
Parish City:
Parish State:
Parish Zip:
Diocese:
How many years has your parish attended: 
Other Group Leader/Church Parish/City/State to be seated with:
 
*Number of spots:  
Number of T-shirts:  @ $15.00 per T-Shirt
   
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  4521 PGA Blvd. #173, Palm Beach Gardens, FL 33418, 561-670-1455, Fax: 561-775-9409, info@steubenvilleflorida.com