CLAPHAM CIRCLES

Primary Contact *

First Name

Last Name

Additional Adult (if applicable)

First Name

Last Name

Phone *

Primary Contact Phone

(###)

###

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Your Day Choice *

Please select your preference. Clapham Circles will meet once a month for three months on the first Wednesday or the second Sunday of the month.

WEDNESDAY DINNER (First Wednesdays @ 6:00-7:30 PM - September 4, October 2, November 6)

SUNDAY LUNCH (Second Sundays @ 1:00-2:30 PM - September 15, October 13, November 10. *NOTE: Groups will meet on third Sunday in September.)

Age Group

Please indicate the age range of the adult(s) attending.

18-29

30-39

40-49

50-64

65+

Location

Please indicate which of the following locations you are comfortable traveling to. Check all that apply.

Greensboro

High Point

Winston Salem

Kernersville

Other (Please indicate in Notes field below.)