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Name
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First Name
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Last Name
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Email address
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Gender
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Male
Female
Do you live in the Central Valley
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Yes
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Age
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Under 20 years old
20-29 years old
30-40 years old
41-50 years old
Above 50 years old
Which describes you best?
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Just accepted Jesus as Lord and savior at the service
A believer of Jesus Christ who is attending Revive City Church and who have just decided to make Revive City Church my new home church
Revive City Church has been my home church for more than a year and i would like to be connected to a group
Just visiting
Which service do you attend?
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Fresno Site
Online Service
Terms of Use Acknowledgement
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I Agree
I acknowledge that I have read and understood the Privacy Policy, and I consent and agree to the collection, use, and disclosure of my personal data for the purpose of my prayer request and for follow up, in accordance with the Privacy Policy and Terms of Use of Revive City Church.
Right To Privacy
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I Acknowledge
If I have provided any personal data of individuals other than myself (e.g. my family and friends), I confirm that I have sought consent from them to the collection, use, and disclosure of their personal data. In particular, I confirm that I have informed these individuals of the purposes of collection, use, and disclosure of their personal data.
I would like someone to contact me.
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Yes
Not at this time
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