Member Contact Form
Where: Salem Lutheran Church, 1700 W. War Memorial Dr., Peoria, IL 61614
Do you wish to receive information about Salem Lutheran Church through:
The Bugle Newsletter (monthly)
The Bugle Blast (weekly)
The Extra (weekly Sunday insert)
All of the Above
Other
Name
*
First Name
Last Name
Home Phone #1
*
-
Area Code
Phone Number
Cell Phone #1
*
-
Area Code
Phone Number
Work Phone #1
*
-
Area Code
Phone Number
Email #1
*
example@example.com
On Facebook? (#1)
*
Yes
No
Name #2
First Name
Last Name
Home Phone #2
-
Area Code
Phone Number
Cell Phone #2
-
Area Code
Phone Number
Work Phone #2
-
Area Code
Phone Number
Email #2
example@example.com
On Facebook? (#2)
Yes
No
Children Information
if applicable
How many children?
Please Select
1
2
3
4
First Child
Child's Name
First Name
Last Name
Grade entering in Fall 2019
Please Select
PreK - 3
PreK - 4
K
1
2
3
4
5
6-8
High School
College
Birthday
-
Month
-
Day
Year
Date
Second Child
Child's Name
First Name
Last Name
Grade entering in the Fall 2019
Please Select
Prek - 3
Prek - 4
K
1
2
3
4
5
6-8
High School
College
Birthday
-
Month
-
Day
Year
Date
Third Child
Child's Name
First Name
Last Name
Grade entering Fall 2019
Please Select
PreK - 3
PreK - 4
K
1
2
3
4
5
6-8
High School
College
Birthday
-
Month
-
Day
Year
Date
Fourth Child
Child's Name
*
First Name
Last Name
Grade entering Fall 2019
*
Please Select
PreK - 3
PreK - 4
K
1
2
3
4
5
6-8
High School
College
Birthday
-
Month
-
Day
Year
Date
Is anyone in your household a member of Thrivent?
Yes
No
If Yes, would you be willing to learn more about using your Action Team Benefit for a Salem Youth Ministries Fundraiser, Service Project or Educational Event?
Yes
No
Questions? please contact Meghan Peterson
mpeterson@salemofpeoria.com
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