1700 Napa Valley Drive - Little Rock, AR, 72212
Office (501) 225-9231
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New Membership Information
New Membership Information
We are so glad you have chosen to make Asbury your church home! Please take a few moments to fill out this information so we can have it for our records. This information will be kept in complete confidence.
First Name
*
Middle Name
*
Last Name
*
Date Joined
*
Title
Mr.
Mrs.
Ms.
Dr.
Rev.
Suffix
Jr.
Sr.
I
II
III
IV
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Home Phone
(***)***-****
Cell Phone
(***)***-****
Work Phone
(***)***-****
Emergency Contact (Name & Relation):
Phone of Emergency Contact
Primary Email Address
*
Alternate Email Address
Birthday
*
mm/dd/yyyy
Baptism Date
mm/dd/yyyy
Place of employment
Occupation
If the new member is a child, list parents' names
Is there a former church?
Yes
No
Denomination?
*
UMC
Other
Can we contact your former church?
*
Yes
No
We would contact your former church to request transfer of membership, and any other pertinent information for our membership rolls.
Name of former church
*
Address of former church
Street Address
City
State / Province / Region
ZIP / Postal Code
Was this the former church of all members of your household?
*
Yes
No
List any other family members joining from this former church
Name
Relation
Add more members by clicking the "+" icon to the right of the 'Relation' field.
Marital Status
*
Single
Married
Widowed
Divorced
Anniversary Date
mm/dd/yyyy
Name of Spouse
First Name
Middle Name
Last Name
Title
Mr.
Mrs.
Ms.
Dr.
Rev.
Suffix
Jr.
Sr.
I
II
III
IV
Cell Phone
(***)***-****
Work Phone
(***)***-****
Emergency Contact (Name & Relation):
Phone of Emergency Contact
Primary Email Address
Alternate Email Address
Birthday
*
mm/dd/yyyy
Baptism Date
mm/dd/yyyy
Place of employment
Occupation
Children?
*
Yes
No
Child 1
First Name
Middle Name
Last Name
Title
Mr.
Mrs.
Ms.
Dr.
Rev.
Suffix
Jr.
Sr.
I
II
III
IV
Birthday
mm/dd/yyyy
Baptism Date
mm/dd/yyyy
Confirmed?
Yes
No
Child 2
First Name
Middle Name
Last Name
Title
Mr.
Mrs.
Ms.
Dr.
Rev.
Suffix
Jr.
Sr.
I
II
III
IV
Birthday
mm/dd/yyyy
Baptism Date
mm/dd/yyyy
Confirmed?
Yes
No
Child 3
First Name
Middle Name
Last Name
Title
Mr.
Mrs.
Ms.
Dr.
Rev.
Suffix
Jr.
Sr.
I
II
III
IV
Birthday
mm/dd/yyyy
Baptism Date
mm/dd/yyyy
Confirmed?
Yes
No
Child 4
First Name
Middle Name
Last Name
Title
Mr.
Mrs.
Ms.
Dr.
Rev.
Suffix
Jr.
Sr.
I
II
III
IV
Birthday
mm/dd/yyyy
Baptism Date
mm/dd/yyyy
Confirmed?
Yes
No
Child 5
First Name
Middle Name
Last Name
Title
Mr.
Mrs.
Ms.
Dr.
Rev.
Suffix
Jr.
Sr.
I
II
III
IV
Birthday
mm/dd/yyyy
Baptism Date
mm/dd/yyyy
Confirmed?
Yes
No
Child 6
First Name
Middle Name
Last Name
Title
Mr.
Mrs.
Ms.
Dr.
Rev.
Suffix
Jr.
Sr.
I
II
III
IV
Birthday
mm/dd/yyyy
Baptism Date
mm/dd/yyyy
Confirmed?
Yes
No
Child 7
First Name
Middle Name
Last Name
Title
Mr.
Mrs.
Ms.
Dr.
Rev.
Suffix
Jr.
Sr.
I
II
III
IV
Birthday
mm/dd/yyyy
Baptism Date
mm/dd/yyyy
Confirmed?
Yes
No
Email
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