Vickery Information Request Form

First Name:

Last Name:

Address:

City:

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Home Phone:

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Your Email Address:

I am a High School student: Yes No

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I would like to be a KIDS HOPE mentor.

I would like to help with Cool Kids.

I would like to help with the After School Program.

I would like more information.

You may use this space to ask questions about ministry opportunities in Vickery: