Today's Date *

MM

DD

YYYY

Name *

First Name

Last Name

Gender *

Male

Female

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone *

(###)

###

####

Permission to Text? *

Yes

No

May we contact you at work? *

Yes

No

Work Phone

(###)

###

####

Do you regularly attend weekend worship services at our church? *

Yes

No

Have you accepted Jesus Christ as your Lord and Savior and are you committed to having the character of Jesus living through you? *

Yes

No

[ONE] Name *

First Name

Last Name

Home Phone *

(###)

###

####

Work Phone

(###)

###

####

[TWO] Name *

First Name

Last Name

Home Phone *

(###)

###

####

Work Phone

(###)

###

####

[THREE] Name *

First Name

Last Name

Home Phone *

(###)

###

####

Work Phone

(###)

###

####

Have you ever been concerned that you may have an addiction to drugs, alcohol, pornography or any other addiction; or has anyone ever suggested that you may have a problem with any of the above? *

Yes

No

Have you ever been arrested, convicted, or pleaded guilty to a crime? *

Yes

No

Have you ever been accused, or charged of an act of neglecting, abusing, molesting or battering any child or adult? *

Yes

No

Have you ever been treated for a psychiatric disorder? *

Yes

No

Has there been any abuse in your family background with drugs or alcohol or that was emotional, physical, or sexual in nature? *

Yes

No

Is there any circumstance or pattern in your life, which would make it inappropriate for you to serve with minors or would compromise the integrity of our church? *

Yes

No

I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding agreement, which I have read and understand. *

Checking this box takes the place of a handwritten signature.

I agree and understand

Date *

MM

DD

YYYY