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Adult Confirmation Payment

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  STUDENT INFORMATION
  
  Today's Date REQUIRED Please fill out this field. Please enter a date.
  
  Last Name REQUIRED Please fill out this field. Please enter valid data.
  
  First Name REQUIRED Please fill out this field. Please enter valid data.
  
  Primary Telephone REQUIRED Please fill out this field. Please enter valid data.
  
  Primary Email REQUIRED Please fill out this field. Please enter valid data.
  
  Street Address REQUIRED Please fill out this field. Please enter valid data.
  
  Apt. # 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.
  
  Registration Fees Assessment
  
  Adult Confirmation Registration Payment REQUIRED 55.0 – Registration and Bible Fee Please fill out this field.
  
  IMPORTANT: Before pressing Proceed to Payment, please go back and review the form to make sure everything is correct.
  
  Total:
  
  Submit
  
  Proceed to Payment
  
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