Membership Registration Form

Instructions: Please complete all sections with * marked as required. Write clearly in BLOCK LETTERS. Attach a recent passport-size photograph in the space provided.

1. PERSONAL INFORMATION

Title

Mr.

Mrs.

Miss

Dr.

Rev.

Prof.

PASTE
PASSPORT
PHOTO
HERE

First Name *

Middle Name

Last Name *

AKA (Also Known As / Nickname)

Date of Birth *

Gender *

Male

Female

Day Born

Sun

Mon

Tue

Wed

Thu

Fri

Sat

Marital Status *

Single

Married

Divorced

Widowed

Home Town

Occupation

Employer

Highest Qualification

None

Primary

JHS

SHS

Tertiary

Postgraduate

2. CONTACT & ADDRESS

Phone *

Address *

City *

Region *

3. CHURCH FAMILY

Select Church Family/Families (Check all that apply)

4. MEMBERSHIP & SPIRITUAL INFO

Membership Type *

Communicant

Baptized

Confirmed

Adherent

Previous Church

Baptized

Date:

Confirmed

Date:

Married

Date:

5. EMERGENCY CONTACT & GUARDIAN (If Minor)

Emergency Contact Name *

Relationship *

Phone *

Guardian Name (if minor)

Guardian Phone

Guardian Address

6. HEALTH & EDUCATION

Medical Conditions/Allergies

Physically Challenged

Type:

Currently Schooling

School Name

School Phone

7. DECLARATION

I declare that the information provided is true and correct. I agree to abide by church rules and regulations.

Receive Email Updates

Receive SMS Updates

Applicant's Signature

Date

FOR OFFICE USE ONLY

Member ID

Date Received

Approved By

Date Approved

Remarks

Signature/Stamp