Jesus Saved My Life Church- Church Registration Form

Jesus Saved My Life Church
Church Registration Form
Full Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Phone Number
Format: (000) 000-0000.
Email Address
example@Jesussavedmylifeministries.com
City
ZIP Code
State
Relationship to Participant
Full Name
Phone Number
Format: (000) 000-0000.
Alternate Phone Number
Format: (000) 000-0000.
Church Involvement
Are you a Member of Jesus Saved My Life Church?
If no, would you like to become a Member?
Preferred Service Time
Areas of Interest
I consent to Jesus Saved My Life Church collecting and storing my personal information forministry and communication purposes.

Iunderstand that photos or videos may be taken during church events and may be used forministry-related media and outreach.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Legal Guardian Section (Required if under 18)
Relationship to Minor
Guardian Full Name
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Address (if different from minor)
Address

Address if different from minor

Street Address Line 2

CityState / Province

Postal / Zip Code
I, the legal guardian of the above-named minor, give permission for participation in all Jesus Saved My Life Ministries activities and events.
I authorize emergency medical treatment if necessary and understand that reasonable efforts will.
Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Medical Information
Do you have any allergies or Medical conditions?
If yes, please specify
Type here
Do you take any medications regularly?
If yes, Please list
Type here
Primary Care Physician Name

First NameLast Name
Primary Care #
Please enter a valid phone number.Format: (000) 000-0000.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Office Use Only
Field
Membership Status
Received By
Date Received

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Jesus Saved My Life Church Bringing hope, healing, and salvation through the power of Jesus Christ. Visit jesussavedmylifeministries.com for more information, upcoming events, and ministry opportunities.
Should be Empty:

Jesus Saved My Life Church

Church Registration Form

Church Involvement

Legal Guardian Section (Required if under 18)

Medical Information

Office Use Only