Membership Information Form

Your Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birth Date

YYYY

Cell Phone or Other Contact Details

(###)

###

####

Parents Name (for under 18 years)

Father and Mother

Marital Status

Single

Married

Divorced

Widowed

If married, Anniversary Date

YYYY

Family (Name of Child)

First Name

Last Name

Birthdate

YYYY

Family (Name of Child)

First Name

Last Name

Date

YYYY

Family (Name of Child)

First Name

Last Name

Date

YYYY

Previous Church Attendance

Name of previous church (if any)

Address of previous church

(if any)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Website of previous church

(if any)

http://

Have you received Jesus Christ as your personal Lord and Savior?

Have you been baptized by immersion upon confession of your faith in Jesus Christ?

If yes to baptism,

Date

YYYY

If yes to baptism,

Name of Church

If yes to baptism,

Address of Church where you were baptized

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

If yes to baptism,

Website of Church (if any)

http://

Do you agree with Statement of Faith held by Immanuel Baptist Church?

If not, please explain.

Signature of Applicant

State your full name

Today's Date

YYYY

Signature of Applicant's Parent

(if under 18)

Today's Date

YYYY

Any Other Comments (Optional)