CHP Mailing List Application
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Please complete this survey if you are interested in being aded to the mailing list for Congregational Health Partnership (CHP) or you would like to add your faith community to the mailing list.
1.
Please indicate:
Dr.
Mr.
Mrs.
Ms.
Other, please specify
2.
First Name
*
3.
Last Name
*
4.
What is the location of the following information?
*
Church
Home
5.
Street Address
*
6.
City
*
7.
State
*
8.
Zip Code
*
9.
Phone Number
*
Do not include spaces or dashes.
10.
Fax Number
Do not include spaces or dashes.
11.
E-mail Address
*
12.
Check the information that you would like to receive:
*
e-Bulletins
Newsletters
Program Announcements
Other, please specify
