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E-mail Address: * Name Address City Zip Daytime Phone Work Phone Cell Phone I am interested in a Life Group that serves (mark all that apply) Men Only Women Only Mixture of Couples & Singles Unmarried Young Adults (23-30) Young married without children Married Adults with infant/toddler Married Adults with elementary age children Married Adults with jr./sr. high children Married Adults College Age (18 - 25) Singles over 30 Jr. High Teens Sr. High Teens Married Again Adults Senior Adults (55+) Empty Nesters Other I am interested in groups that meet in: West Medford East Medford Eagle Point/Shady Cove Central Point Phoenix/Talent Jacksonville Applegate/Ruch Other * Required