Wholeness Center Registration Form

EZION FAIR Baptist Church & CDC, Inc. Wholeness Center Membership Registration
Date *

Month Day Year
Date
Last *
First *
Middle
Date of Birth *

Month Day Year
Date
Street *
City *
State *
Zip *
Telephone No. *
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 Initial after each statement.
Type a question *

I will at no time be in possession of or bring drugs or alcohol on EFBC Campus I will at no time be in possession of or bring fire-arms or weapons on EFBC Campus I will at no time verbally or physically assault any person while on EFBC Campus I will conduct myself in a peaceful and respectful manner while on EFBC Campus I understand that my membership rights end when they begin to infringe on the rights of others I will respect EFBC by refraining from using any vulgar vituperative language
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 *

Month Day Year
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

Month Day Year
Date
Should be Empty:

Emergency Contact Information

Oath & Promise