Database Enrollment

Please complete all portions of this on-line enrollment form. Your response will only be seen by our Association office staff. When you are finished, be sure to click on the 'Submit' button. Thank you.

YOUR CONTACT INFORMATION

Your Name

Your Preferred Email

This address will receive a confirmation email

Home Phone

Cell Phone

Do you regularly use e-mail?

Please select one option.

Yes No

Do you regularly use text messaging on your cell phone?

Please select one option.

Yes No

Do you have a Facebook profile?

Please select one option.

Yes No

Home Address

Mail Address (if different)

We would like to send you our monthly newsletter. Is that OK?

Please select all that apply.

Yes No

How would you like for us to send you the newsletter?

Please select all that apply.

Via e-mail Via text messaging I don't use e-mail or text messages - please send it through the mail

Gender

Please select all that apply.

Male Female

YOUR FAMILY INFORMATION

Name Of Spouse (if applicable)

Your Marital Status

Please select one option.

Never Married Married No Longer Married Widow or Widower

Name Of Other Adult(s) Residing With You - And Their Relationship To You

Name Of Child(ren) Living With You - And Their Relationship To You

Name Of Child(ren) Not Living With You - And Their Relationship To You

YOUR CHURCH INFORMATION

With which church do you identify?

Please select one option.

Other Bethel Creek Beulah Brewer Lake Central Cherry Lake First Concord Elizabeth Faith Fellowship Greenville Harmony Hopewell Lamont Lee First Macedonia Madison First Mayo Midway Morningstar Mount Olive New Home New Macedonia Olive Pine Grove Pinetta First Pleasant Grove Riverside Saint John's Sirmans The Journey Unity None

Are you a member there?

Please select one option.

Yes No Not Sure

If Other, Please Identify The Church

YOUR EMPLOYMENT INFORMATION (optional)

Name Of Employer

Job Status

Please select one option.

Full Time Part Time Contract Seasonal Retired

That's it - you're finished! Thank you very much for supplying the information to us. All you need to do now is click on the 'Submit' button below and you're all done.

Database Enrollment

Description

Please Fix the Following