Language
English (US)
Español
Agape Church Membership Application
Please complete all of the following to be considered for general membership with Agape Church. This information will be reviewed thoroughly by our team, and you will be contacted by one of our team members with any questions so please ensure the accuracy and truthfulness of all of your answers. Thank you!
Completing this form will not grant you AYNI benefits. This form is for general membership only. In order to become an Ayni member, you must first attend a qualifying retreat.
Personal Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Only applicants of 18 years and older are considered at this time.
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Who referred you to Agape Church?
*
Please enter the name of the Individual, Social Media Platform, Search Engine, etc.
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Back
Next
About You
Marital Status
*
Single
Married
Do you have children?
*
Yes
No
Are you currently employed?
*
Yes
No
Best time to contact you?
*
Morning
Evening
Why are you applying to become a member of Agape Church for Soul, Mind & Body?
*
0/200
Are you a member of the Armed Forces, Veteran, First Responder or Frontline Healthcare Worker?
*
Yes
No
What talents or skills do you possess that you'd like us to be aware of?
What leisure activities do you like to participate in?
What religious affiliation do you currently identify with? (if none, enter n/a)
*
Religious affiliation data is for research purposes only.
Do you consider yourself to be spiritual, mindful and/or religious?
*
Yes
No
Do you currently engage in prayer or meditation practices?
*
Yes
No
Back
Next
Medical History
Do you have any physical, psychological or emotional medical conditions that we should be made aware of that may pose a threat to your health and safety or the health and safety of other congregants?
*
Yes
No
If yes, explain in detail below. If no, skip to next question.:
Do you currently rely on prescription medications for an existing medical condition?
*
Yes
No
If yes, explain in detail below. If no, skip to next question.:
Do you require assistance from medical device(s)? (including but not limited to inhalers, wheelchair, CPAP machine, pacemaker, etc.)
*
Yes
No
If yes, explain in detail below. If no, skip to next question.:
Back
Next
Membership Statements
Please review and accept each of the following statements for membership consideration. It is important that you sincerely agree with the statements below in their entirety, so please answer truthfully. If you disagree with any of the following statements, please do not submit this form and contact us immediately.
During the entire process of completing this membership form, I have been and am currently of sound mind and body, acting in my own faith and best interests without duress or undue influence.
*
I confirm and understand the statement above to be true and accurate.
I understand that my membership with Agape Church and Healing Center for the Soul, Mind and Body is solely for religious and/or spiritual purposes.
*
I confirm and understand the statement above to be true and accurate.
I understand that any false statements provided within this application could result in the removal of my application or revocation of my membership.
*
I confirm and understand the statement above to be true and accurate.
I am a consenting adult of sound mind and body. I may voluntarily, without duress or undue influence, choose to partake in “plant-based” ceremonial sacrament rituals held by Agape Church for Soul, Mind and Body (a 508c1a non-profit faith-based organization) for spiritual and religious purposes. I am acting out of faith, and faith alone in communing with these sacraments in ceremony. I am aware of the risks associated with my participation and, by affixing my consent below, waive all liability for the sacrament officiant(s), their agents, and associations into perpetuity.
*
I confirm and understand the statement above to be true and accurate.
Submit
Signature
*
Should be Empty: