Wholeness Center Registration Form

Ezion Fair Baptist Church & CDC, Inc.

Wholeness Center Member Registration
Date*

MonthDayYear
Date
Last*
First*
Middle
Date of Birth*

MonthDayYear
Date
Street*
City*
State*
Zip*
Telephone No.*
Email*
example@example.com
Are You A Member of Ezion Fair Baptist Church?*
Since
Emergency Contact Information
Name*
Relationship*
Street*
City*
State*
Zip*
Telephone No.*
If an emergency occurs, do we have permission to transport to hospital?*
Oath & Promise
Please Check Each Statement:

I WILL NOT, at any time be in possession of or bring drugs or alcohol on the EFBC Campus.I WILL NOT, at any time be in possession of or bring drugs or alcohol on the EFBC Campus.I WILL NOT, at any time verbally or physically assault any person while on the EFBC Campus.I WILL conduct myself in a peaceful and respectful manner while on the EFBC CampusI WILL respect EFBC by refraining from using any vulgar language and profanityI WILL take full liability for any damage I cause to the property.I UNDERSTAND that my membership rights WILL BE REVOKED when my behavior begins to infringe upon the rights of others.
My signature acknowledges that I have read, understand and completed all of the above information to the best of my knowledge. By signing here, I understand that I must abide by all rules and regulations of the federal government, state, city and center and may lose all rights and privileges to the use of these facilities if I cannot do so.*

Clear
Date*

MonthDayYear
Date
If Applicant Is Under 18-Years Old
Parent
Telephone No.
My signature indicates that I am giving my child permission to use the Ezion Fair Baptist Church's facilities and will be responsible for his/her actions & activities.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Emergency Contact Information

Oath & Promise