Membership Information for West Irving Church of God in Christ

West Irving Church of God in Christ Membership Information
Please include as much information as possible, including complete date of birth. Regarding children, list only those who are under 18, physically residing with you, who attend West Irving Church of God in Christ.

Please DO NOT use all caps.

Household Information

Mailing (Primary) Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Wedding Date

- Month - Day Year
Church Member or Attender Status *

Members of West Irving Church of God in Christ Regular attenders Occasional attenders Visitors Members of another church (see next question)
Name of your home church if not West Irving Church of God in Christ

Your Information
Full Name *

First Name Last Name
Goes by--if different from first name
E-mail
Phone Number

- Area Code Phone Number
Birth Date

Month Day Year

Spouse's Information
Spouse's Name

First Name Last Name
Spouse Goes by--if different from first name
Spouse's E-mail
Spouse's Phone Number

- Area Code Phone Number
Spouse Birth Date

Month Day Year
In Case of an Emergency:
Emergency Contact Name

First Name Last Name
Relationship:
Contact Number:
Is this person your durable power of attorney?
Alternate Contact Name:
Relationship:
Contact Number:
Is this person your durable power of attorney?
Ministry
Title
Your Ministry Involvement
Spouse's Ministry Involvement

Child 1 Information
Please only list children under 18, physically residing with you, and attending West Irving Church of God in Christ.
How many children to you have?
c1 Full Name

First Name Last Name
c1 Gender

Male Female
c1 Birth Date

Month Day Year
c1 Grade in School
c1 E-mail
c1 Cellphone

- Area Code Phone Number

Child 2 Information
Please only list children under 18, physically residing with you, and attending West Irving Church of God in Christ.
child2 Full Name

First Name Last Name
c2 Gender

Male Female
c2 Birth Date

Month Day Year
c2 Grade in School
c2 E-mail
c2 Cellphone

- Area Code Phone Number

Child 3 Information
Please only list children under 18, physically residing with you, and attending West Irving Church of God in Christ.
child3 Full Name

First Name Last Name
c4 Gender

Male Female
c3 Birth Date

Month Day Year
c3 Grade in School
c3 E-mail
c3 Cellphone

- Area Code Phone Number

Child 4 Information
Please only list children under 18, physically residing with you, and attending West Irving Church of God in Christ.
child4 Full Name

First Name Last Name
c4 Gender

Male Female
c4 Birth Date

Month Day Year
c4 Grade in School
c4 E-mail
c4 Cellphone

- Area Code Phone Number

Child 5 Information
Please only list children under 18, physically residing with you, and attending West Irving Church of God in Christ.
child5 Full Name

First Name Last Name
c5 Gender

Male Female
c5 Birth Date

Month Day Year
c4 Grade in School
c5 E-mail
c5 Cellphone

- Area Code Phone Number

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