Welcome to the

Libertas Society!

Name _________________________________

                       First                      MI             Last

Email address(es): __________________________

Date: _____________________

Phone # (not required):

Cell: ___________________

Dorm: Ext. #____________

□   I am willing to be contacted about speaking with my pastor, church administrator, or the leader of some other local Christian/conservative network about involvement in the Libertas Society (Not required)

If you checked the box above, please list the local church or other organization that you would like to involve in the Libertas Society’s social action: ________________________________

 I am registered as a citizen of __________________________
                                                   City/Co.                 State