Delaware and Maryland Youth Development Network

Name:
Address:

______________________________________________
______________________________________________
City: ___________________ State: _____ Zip: ______
Church Name:
__________________________________________
Church Address: __________________________________________
City: _______________ State: _____ Zip: _____
Phone Number(s): Home: ____________________
Cell: ____________________
Primary Email:
__________________________________________
Secondary Email: __________________________________________
Birth date: ___/___/______
Facebook (circle): yes no
Instagram (circle): yes no
Instagram Name: _______________
For future network meetings please answer the following questions:
1. Preferred day of week to meet (list 3 days) ?
1st pick:
2nd pick:
3rd pick:

2. How far are you willing to travel for a network meeting?

3. What time (after 5pm) would be ideal to meet?
4. What are some topics you want our network to discuss?