Community Dialog
Participant Form

Name ____________________________________
Phone ______________________
Address ________________________________________
Fax ______________________
Email ______________________
City _________________ State ____ Zip _________

Dialog Location ___________________
Leader(s) ____________________
Date __________

o Yes  o No  Please add me to the FIC mailing list.
o Yes, ..... But don't share my name with other like-minded groups.
o Yes  o No  I might want to help organize and host 
               another Dialog session.
o Yes  o No  I am interested in sharing skills/expertise or 
               becoming more involved in FIC work.
o Yes  o No  I am currently a member of FIC.
o Yes  o No  I have lived in an intentional community.  
               o Past  o Currently
               How long? _______________
               Name of community? _____________________

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