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First Name
Last Name
Primary Phone Number
Gender
Male
Female
I'd rather not say
Address
Apartment, suite, etc.
City
State
Zip/Postal Code
Deitary Restriction
None
No Pork
Vegetarian
Vegan
Other
Dietary Restriction
Allergies
Any Significant Health Conditions
Yes
No
Significant Health Conditions
Diabetic
Dementia
high Blood Pressue
Arlhritis
Asthma
COPD
Heart Disease
Chronic Kidney Desease
Other
Other
Do you or the participant live independently
Yes
No
Does participant or you need transportation to Vergennes Church? (only available within 5 miles)
Yes
No
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