Life Center - Rockford IL

Rockford Life Center
815.964.4966
921 W. State St.
Rockford, IL 61102

Please fill out the application and send your check of $80.00 to Life Center 921 West State Street Rockford IL 61102. Checks should made out to the Life Center.

Name:
Email:
Address:
City:
State: *
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Home Phone:
Work Phone:
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Best Time to Reach You:
Status: *
Age:
Birth Date:
Where do you attend school (if applicable):
Do you attend church?:
If so, where?:
Are you a member?:
Do you have a personal relationship with Jesus Christ?:
How long have you been a Christian?:
How did you hear about Purity with Purpose?:
What are you expecting from this course?: