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Membership Information


Service Date:*
 / 
 / 
Service Time:*
Name:*
Gender:*
Marital Status:*
DOB:
 / 
 / 
Address:*
Phone(H):
-
Phone(C):
-
E-mail Address:
Occupation:
Are you related to a current member of The Park Church?:*
If Yes, Member Name:
If Yes, Relationship:
Are you a current college student?:*
If Yes, What college:
Emergency Contact Name:
Emergency Contact Phone:
-
** Other Youth
(between the age of 5 & 15)

I would like to become a member of this church, but my parents are not in church today.  They must be contacted before I can become a member. (NOTE: Assimilation Leader, if parent is in the Adult Membership Room,*PLEASE OBTAIN DECLARATION INFO FROM CHILD'S PARENT)


Desires Membership By:

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