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St. Dymphna Mass Registration Form

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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.
  
  Phone Number REQUIRED
  
  Please fill out this field. Please enter a phone number.
  
  Address 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.
  
  Number of Attendees - include yourself and others you are registering REQUIRED Please fill out this field. Please enter valid data.
  
  Names of Others you are registering
  
  Accommodation Requests: please list any dietary needs here, as well as requests such as: large print materials, assistance getting to and from your car, wheelchair use, ASL interpreter, low gluten hosts, and/or sensory items.
  
  I am interested in carpooling and would like to be connected with others in my city (please note that we are not able to coordinate rides, but we are able to connect you with others for you to coordinate rides if you would like) REQUIRED Yes No I can drive, please share my contact information with anyone in my city/town who is looking to carpool Please fill out this field.
  
  Volunteer interest: if you are interested in volunteering, please let us know what you would like to help with or say that you're open to any area and we will assign you with an area and contact you with details closer to the retreat.. Please enter valid data.
  
  I acknowledge and give permission that any photos or videos taken during this event may be used for promotional or ministry purposes. REQUIRED Yes No Please fill out this field.
  
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