Send Completed form to:
Lorri Seiger, C/O Cincy/NKY Pagan Pride Day, PO Box 296 Bethel, OH 45106

Name of Group: ________________________________________________

Contact Person�s Name: _________________________________________

Location: _____________________________________________________

Address: ______________________________________________________

City: ________________________________ State: ___________________

Zip: ______________________Phone # ____________________________

Email address: _________________________________________________

Website URL: _________________________________________________

Type of Group:(check one)
___ Church
Accepting Members: Yes ___ No: ___
___ Coven
Accepting Members: Yes ___ No: ___
___ Group
Accepting Members: Yes ___ No: ___
___ Grove
Accepting Members: Yes ___ No: ___
___ Open Study Circle
Accepting Members: Yes ___ No: ___
___ Organization
Accepting Members: Yes ___ No: ___
___ Other
Please explain
________________________________________________________________________________
________________________________________________________________________________

Do you want to be listed in the Directory ? ___Yes ___No
Do you have information to place on the information table at the Cincy/NKY Pagan Pride Day event? ___ Yes ___No

*****************************************************************************

Date Submitted: _____________ Received by: ______________________