*****2001 PROJECT KOKORO MEMBERSHIP FORM*****

Name___________________________________________ Birthdate_____________

E-Mail Address__________________________

Name___________________________________________ Birthdate_____________

E-Mail Address__________________________

Mailing Address__________________________________

Telephone (____)___________________

Emergency Contact:______________________________

Telephone (____)___________________

Please print and mail completed form to:

Project Kokoro

c/o: Helen Sun

 9112 McFadden Ave.

 Westminster, CA 92683