New Member Data Form - Adult

Last Name (required)
First Name (required)
Middle (Maiden) Name
Preferred Name

Street Address
City
State Zip

Primary Phone (required)
Listed?  yes no

Primary Email
Do you wish to receive weekly e-News?  yes no

Gender  M F
Date of Birth (m/d/y)
Birthplace (City/State)
Ethnic Origin  Caucasian African American / Black Asian / Pacific Islander Native American Hispanic Other

Previous Church Membership
 ELCA Lutheran Other Lutheran Non-Lutheran None
Name of Church
Address (City/State)
Baptized?  yes no --- Date of baptism (m/d/y)
Baptism Church (Name/City/State)
Confirmed?  yes no --- Date of Confirmation (m/d/y)
Confirmation Church (Name/City/State)

Occupation
Employer
Employer Address
Work Phone
Educational Level  High School College Graduate/Professional

Marital Status  Single Married Divorced Widowed
If Married - Date of Marriage
Location (Church/City/State)
Spouse's Name
Father's Name
Mother's Name

Children Residing in Home
 Parent Stepparent Guardian Other
 Parent Stepparent Guardian Other
 Parent Stepparent Guardian Other
 Parent Stepparent Guardian Other

For security purposes, please enter these letters and numbers in the following entry box.

After you complete the form, hit the (Send). If there are no errors, the information will be sent in an email to the church office.