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Registration
Member #
*
First Name
*
Last Name
*
Address 1
*
Address 2
City
State/Province
ZIP / Postal Code
Home Phone
Cell Phone
*
Email Address
*
Birthday
*
Month
*
Day
*
Year
*
Gender
*
Please select an option
Select
Male
Female
Martial Status
*
Please select an option
Select
Single
Married
Widow(er)
Retiree
*
Yes
No
College Student
*
Yes
No
Military Personnel
*
Yes
No
Home Bound/Nursing Home
*
Yes
No
Emergency Name
*
Emergency Relationship
*
Please select an option
Select
Spouse
Brother
Father
Mother
Sister
Friend
Other
Emergency Phone
*
Notifications
Yes
No
Would you like to receive notifications regarding church information?
Notification Preference
Select
Phone Call
Text
Email
Website
Is the registrant between the ages of 1-19?
Yes
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