SHINE 2025 Connect Card

SHINE// A Jesus Church Connect Card

We are so glad you are here!
I'm New to SHINE*

YesNo, we have been attending for a whileJust updating our info
Adult 1*

First NameLast Name
Adult 1 Phone Number*
Please enter a valid phone number.
Adult 1 Email*
example@example.com
Adult 1 Birthday*

MonthDayYear
Date
Adult 2 Name

First NameLast Name
Adult 2 Phone Number
Please enter a valid phone number.
Adult 2 Email
example@example.com
Adult 2 Birthdate

MonthDayYear
Date
Address of Family*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Children's and Youth info below Please fill out for your children that are under 18 and live in the home with you.
Child/Youth

First NameLast Name
Gender

MaleFemale
Phone Number of Youth Student if applicable
Please enter a valid phone number.
Birthdate

MonthDayYear
Date
Grade of Child/ Youth
Do they have any allergies/ medical conditions that we should know about?
Child/Youth

First NameLast Name
Gender

MaleFemale
Phone Number of Youth Student if applicable
Please enter a valid phone number.
Birthdate

MonthDayYear
Date
Grade of Child/ Youth
Do they have any allergies/ medical conditions that we should know about?
Child/Youth

First NameLast Name
Gender

MaleFemale
Phone Number of Youth Student if applicable
Please enter a valid phone number.
Birthdate

MonthDayYear
Date
Grade of Child/ Youth
Do they have any allergies/ medical conditions that we should know about?
Child/Youth

First NameLast Name
Gender

MaleFemale
Phone Number of Youth Student if applicable
Please enter a valid phone number.
Birthdate

MonthDayYear
Date
Grade of Child/ Youth
Do they have any allergies/ medical conditions that we should know about?
Should be Empty:

SHINE// A Jesus Church Connect Card

Children's and Youth info below Please fill out for your children that are under 18 and live in the home with you.