Episcopal Campus Ministry Interest Response

Please fill out this form so that we may contact you and tell you more about what we are currently doing. You may fill out as much or as little of the form as you feel comfortable with.

First Name*: Last Name*:

female male

College*: Class Year:

Campus Address:

City State: Zip:

e-mail*: local phone*:

May we contact you by phone or e-mail? yes no

Denominational Affiliation:

Episcopal
Lutheran
Roman Catholic
Methodist
Baptist
Presbyterian
UCC
Nondenominational Christian
None
Other (please specify)

Permanent Address:

City: State: Zip:

Permanent Phone:

questions/comments

* - denotes required
Contact the Episcopal Chaplain directly: The Rev. Gregory M. Wilson or 610-525-2486 x13
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