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Title:    Mr.    Mrs.    Miss    Ms.

Name:

Street address:

City/Town:

Virginia County or City in which you live:



State:      Zip Code:
      

Phone Number:

E-mail address:

Interests and Hobbies:

I would like to work with the following types of clubs:

School
Community
Special Interest
No Preference
Don't Know

I would like to work with the following ages:

5-8 (Cloverbuds, where available)
9-11 Juniors
12-13 Intermediate
14-19 Seniors
No Preference
Don't Know