New Member Intake Form

House of Anointing Restoration Center
"Where people are restored inside out"
New Member Intake Form
We are honored by your decision to join the HARC Fire family. Please tell us more about yourself by filling out the form below.
Full Name
Address
City
Zip Code
Home Phone
Work Phone
Please enter a valid phone number.
Cell Phone:
Other Phone:
If married, how long?
Date of Birth
Age
Gender

MaleFemale
Email
example@example.com
Occupation
Marital Status

SingleEngagedMarriedSeparatedDivorcedWidowed
Family Information
Spouse's Name
Do you Have Children?

YesNo
If yes, please list their names, gender & age
1.
2.
3.
3.
5.
Emergency Contact #1
Name
Relationship
Home Phone
Please enter a valid phone number.
Cell Phone
Emergency Contact #2
Emergency Contact #2 Name
Relationship
Home Phone
Cell Phone
Date

MonthDayYear
Date
Should be Empty: