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Name: ______________________________________________________________________ |
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Address: ____________________________________________________________________ |
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____________ _______________________________________________________________ |
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Telephone Number: (___) - ___ - ____ |
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Parent's Name |
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Mother _____________________________________________________________________ |
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Father ______________________________________________________________________ |
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Church _________________________________________________________ AME Church |
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Conference____________________________ |
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Institution of higher learning you plan to attend _______________________________________ |
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____________________________________________________________________________ |
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Student's Signature |
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Parent's Signatue |
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Bishop/Supervisor's Signature |
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Episcopal District M-SWAWO President |
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