Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

MM

DD

YYYY

Ethnicity

Select one option, if not listed type in the line below

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

White

None of the above

How Received

Reception......

Stepping forward for the first time professing your faith in Jesus Christ as your Lord and Savior.

Re-committing your profession of faith in Jesus Christ as your lord and Savior and becoming a member of a local church for the very first time.

Re-committing your active engagement in a local church.

Transferring your membership from another United Methodist Church or from another church

Mother's Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Father's Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Legal Guardian's Full Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

If applicable, is your child/youth part of First Church youth program?

Yes

No