Membership Form
Information provided will be handled with high privacy and confidential.
FULL NAME
*
First Name
Last Name
PHONE NUMBER
*
Please enter a valid phone number.
Format: (000) 000-0000.
DATE OF BIRTH
*
-
Month
-
Day
Year
MM / DD / YYYY
EMAIL
example@example.com
ADDRESS
Street Address
Street Address Line 2 (example: Apartment or Floor #)
City
State / Province
Postal / Zip Code
OCCUPATION OR CAREER
EMPLOYMENT STATUS
Employed (employee)
Self-Employed (business owner)
Unemployed (not working)... Please circle applicable reason: Student or Retired
MARITAL STATUS
Single
Married filing jointly
Married filing separately
LIST YOUR UNDER 18 DEPENDENTS LIVING IN YOUR HOUSEHOLD
Full Name (First and Last), Gender (Male of Female), Birthday (MM / DD / YYYY)
AREA(S) OF INTEREST WITHIN OUR CURRENT AUXILIARY GROUPS/TEAMS
Cleaning
Men's Fellowship
Dinner/Food Pantry
Praise & Worship
Evangelistic
Treasury
Events
Ushers
Helps
Welcome
Marriage
Youth
Media
GROUPS* OR ORGANIZATIONS YOU WOULD LIKE TO HELP US PARTNER WITH
*Groups: areas not in the ministry that you want to help establish in FHGCM. Groups and Organizations must align with FHGCM's Mission and Vision.
Have you seen a therapist or counselor in the past?
Yes
No
Have you been diagnosed with a mental illness or emotional problem in the past?
*
Yes
No
Are you currently seeing a therapist or counselor?
Yes
No
Are you taking any prescribed medication?
*
Yes
No
Who can we contact in case of an emergency?
*
Name, Relationship, Phone number.
Signature
*
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