Name:  ______________________________________________

Address: _____________________________________________

City: _________________   State: ______    Zip: ___________

Home Phone: ___________       Cell Phone:_______________

e-mail:_______________________________________________

Home Church: ________________________________________

Send this form along with $20 for adult or $5 for students to:

F.O.C.A.S.

c/o James Shelton

338 Wildflower Way

Cadiz, Kentucky  42211