Walking With Purpose Registration

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First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.
Email REQUIRED Please fill out this field. Please enter an email address.
Address REQUIRED Please fill out this field. Please enter valid data.
City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.
Cell Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
Meeting time (MQ Main Hall) REQUIRED Tuesday 10:30 a.m. Tuesday 7:00 p.m. Please fill out this field.
Home Parish REQUIRED Please fill out this field. Please enter valid data.
Age Group REQUIRED 20-29 30-39 40-49 50-59 60-69 70+ Please fill out this field.
I hereby REQUIRED DO grant permission for Walking with Purpose at Mary Queen to use my photo or video taken throughout the study for use on the Mary Queen website but not limited to advertising, publicity, promotion, or social media DO NOT grant permission for Walking with Purpose at Mary Queen to use my photo or video taken throughout the study for use on the Mary Queen website but not limited to advertising, publicity, promotion, or social media Please fill out this field.
*Registration will not be complete until payment is received.

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Mary Queen