Page 16 | Hillside Church of Brooksville

Name (Required)

Email Address (Required)

Prefix (Required)

Select One

Mr.

Mrs.

Miss

Dr.

Rev.

Your Phone Number (Required)

Birthday (Required)

Wedding Anniversary

if applicable

Your Address (Required)

Makes the following commitment (Required)

Please select all that apply:

Accepts Christ as Personal Saviour and Lord

Desires Membership in this Church by Baptism

Desires Membership in this Church by Statement

Dedicates Life for Church Related Vocation

Rededicates Life to Christ

Desires Membership in this Church by Letter from (name and address of the church below)

Other:

Answer provided under ‘Other’:

Family Member(s) Details

Spouse's Name and Last Name

Spouse's E-mail

Spouse's Phone Number

Spouse’s Birthday

1. Child's Name and Last Name

1. Birthday

2. Child's Name and Last Name

2. Birthday

3. Child's Name and Last Name

3. Birthday

4. Child's Name and Last Name

4. Birthday

5. Child's Name and Last Name

5. Birthday

6. Child's Name and Last Name

6. Birthday