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Name
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First
Last
What is your gender
Male
Female
Other
Email
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Phone Number ( Please enter)
Do you know Jesus Christ
Yes
No
I want to know him
I want to know him more
What is your preferred day to worship Jesus Christ
Every day because it doesn't matter
Sunday
Saturday
Other
What is your age category
*
10-13
14-16
17-25
26-35
36-50
51+
What level of education have you completed?
First Middle School
High school
Undergraduate
Graduate
Post graduate
What is your housing situation
I live with my parents
I live with my mother
I live with my father
I live alone renting
I live alone and I own my home
What is your relationship status
Married
Single (widow widower)
I want to get married
I have a significant other
My significant other is
Male
Female
What are your feelings about life today
My feelings are not important
Life in this world is not good
Life in this world will not change my relationship with Jesus Christ
I am unhappy and ask for prayer
I am unhappy and don't know what to do
I am happy because of Jesus Christ
What is the most important thing to you right now
*
What do you need the most right now
A friend
Prayer
To talk to someone
Bible study
A text message or email
Please share why
*
Please share anything about yourself, friends or family
*
These are the reasons that I am successful
*
These are the reasons that I am happy
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