Church Membership Form

APPLICATION FOR CHURCH MEMBERSHIP
Name

First NameMiddle NameLast NameSuffix
Gender

MaleFemale
Marital Status

SingleMarriedDivorcedWidowed
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Anniversary Date (if Married)

MonthDayYear
Date
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
If You are Under Age 18, Name of Parent/Guardian:

First NameLast Name
Your Household Information
Spouse's Name (If Married)

First NameMiddle NameLast NameSuffix
Spouse's Date of Birth

MonthDayYear
Date
Spouse's Email
example@example.com
Spouse's Mobile Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Is Spouse Also Taking Membership?
Name of Dependent Child 1 (if applicable)

First NameMiddle NameLast NameSuffix
Dependent Child 1's Date of Birth

MonthDayYear
Date
Is Dependent Child 1 Also Taking Membership?
Name of Dependent Child 2 (if applicable)

First NameMiddle NameLast NameSuffix
Dependent Child 2's Date of Birth

MonthDayYear
Date
Is Dependent Child 2 Also Taking Membership?
Name of Dependent Child 3 (if applicable)

First NameMiddle NameLast NameSuffix
Dependent Child 3's Date of Birth

MonthDayYear
Date
Is Dependent Child 3 Also Taking Membership?
Name of Dependent Child 4 (if applicable)

First NameMiddle NameLast NameSuffix
Dependent Child 4's Date of Birth

MonthDayYear
Date
Is Dependent Child 4 Also Taking Membership?
Note: If you have more than 4 children living at home, you may add their information in the comments section at the bottom of the form.
Are you currently a member of another local church?

YesNo
If Yes, name of other church
Name of Pastor
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Are you relocating from another area?

YesNo
Were you a member of a church there?

YesNo
If Yes, name of other church
Name of Pastor
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Have you accepted Jesus Christ as your Savior?

YesNo
If yes, when?
Have you been baptized in water?

YesNo
If yes, when?
Will you support Regional Church with your: prayers, attendance, ministry gifts, and financial support?

YesNo
Would you like to share with us a short testimony of your salvation? (optional)
Other comments, if any:
Thank you for taking the time to fill out this Application for Church Membership form. Church membership is vital to your spiritual growth. My desire is that we grow together in love, maturity, and Christlikeness. Let’s commit ourselves to each other. Together we are stronger. Together we reflect Christ’s image more fully. Together, we can make Jesus Famous to the World! Blessings to you, Pastor Mitchell Bias
Signature
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APPLICATION FOR CHURCH MEMBERSHIP