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Cancer & Domestic Violence Awareness Recognition Form

As part of Cancer & Domestic Violence Awareness Month, Floyd Chapel Baptist Church would like to acknowledge and honor members who have been impacted by cancer or domestic violence.

First Name

Last name

Email

Phone Number

Please select the area that applies to you:

Cancer

Domestic Violence

If Cancer, what type of cancer?

Please select your journey/status:

Survivor

Currently Fighting

May we include your name as part of our October Awareness recognition?

Yes

No

💗💜 Cancer & Domestic Violence Awareness Recognition Form