Clearwater Chinese Christian Church Membership Form

Clearwater Chinese Christian Church Membership

Registration Form
清水華人基督教會會員登記表
Please fill in and submit the form below. Name and Phone number are required (see Red Asterisk), others are optional. If you have trouble with the form, please contact brother IMIN CHEN at 727-504-6758, drop a message for assistance. Thank you!

請填寫下列表單，姓名及電話為必需填寫欄(紅星標註 )，其他為選項，如果您有任何填寫問題，請致電陳逸民弟兄電話 727-504-6758 留言尋求幫助，謝謝！
Name 姓名*

First Name 名Last Name 姓
Phone Number 電話*
E-mail 電子郵件
example@example.com
Address 住址

Street Address 街名

Street Address Line 2 街名2

City 城市State 州名

Zip Code 郵區碼
Emergency Contact Information

緊急聯絡人信息
Primary Emergency | Contact Name 優先緊急聯絡人*

First Name 名Last Name 姓
Primary Emergency | Phone Number 優先緊急聯絡人電話*
Please enter a valid phone number.
What is your relationship with this person? 與優先緊急聯絡人關係？*
Secondary Emergency | Contact Name 第二緊急聯絡人

First Name 名Last Name 姓
Secondary Emergency | Phone Number 第二緊急聯絡人電話
Please enter a valid phone number.
What is your relationship with this person? 與第二緊急聯絡人關係？
Should be Empty:

Clearwater Chinese Christian Church Membership