Student Membership Registration Form

Student membership is 18 and younger
Note: Student membership will not receive the printed newsletter but will be able to access the newsletter online.

Name	Age Birthday (mm/dd/yy)
Street Address
Street Address-2
City, State, Zip	MUST have the +4 zip
Phone Number
Email Address
Are you a member of other Lightouse Organizations? (Check if yes)

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This page last updated: Monday, May 23, 2011 9:17 AM