Membership Registration Form

1. BASIC INFORMATION

Title

Mr.

Mrs.

Miss

Dr.

Rev.

Prof.

PASTE
PASSPORT
PHOTO
HERE

Surname *

Othername(s) *

Old Membership ID (if any)

Date of Birth

Place of Birth

Gender

Male

Female

Nationality

Hometown

AKA (Also Known As)

Residential Address

Digital Address

Telephone Number (Main) *

Telephone Number (Other)

Postal Address

Email Address

Father's Name

Mother's Name

Next of Kin's Name

Next of Kin's Contact

Emergency Contact Person's Name

Emergency Contact Person's Phone Number

2. SOCIAL MEDIA

Facebook

Twitter

Instagram

YouTube Channel

3. FAMILY INFORMATION

Marital Status

Married

Single

Divorced

Widow / Widower

Spouse Name

Spouse Contact Number

Do You Have Any Child / Children?

Yes

No

Number of Children

Child	Name	Child Membership
Child One		Member External
Child Two		Member External
Child Three		Member External
Child Four		Member External
Child Five		Member External
Child Six		Member External
Child Seven		Member External
Child Eight		Member External
Child Nine		Member External
Child Ten		Member External

4. ACADEMIC / PROFESSION

Highest Educational Level

Basic School

Technical School

Secondary School

Tertiary

Master's Degree

Doctorate Degree

Other

Educational Institution (e.g. Presby Middle School - Bomfa, Pakyi SHS - Pakyi No. 1, KsTU, UCC, etc)

Academic Qualification (e.g. O' Level, SSSCE, Diploma in ...., HND ...., BSc ...., etc)

Profession (e.g. Trader, Teacher, etc)

Occupation (e.g. Trading, Teaching, etc)

Employer

Employment Status

Employed

Unemployed

Retired

Student

5. CHURCH SECTION

Date of Baptism

Place of Baptism (Name of Church and Location/Town)

Baptised By (Minister's Name)

Date of Confirmation

Place of Confirmation (Name of Church and Location/Town)

Date Joined

Confirmed By (Minister's Name)

Service Group

Bible Sudies and Prayer Group

Boys and Girls Brigade

Choreography

Church Choir

Prayer Tower

Singers Team

Singing Band

Ushers

Others:

Bible Studies Group

Day Born Group

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Communicant / Non-Communicant

Communicant

Non-Communicant

Any Special Role (Presbyter, Catechist, IMC, Evangelist, etc)

6. EMERGENCY CONTACT & GUARDIAN (If Minor)

Relationship to Emergency Contact

Emergency Contact Occupation

Guardian Name (if minor)

Guardian Relationship

Guardian Phone

Guardian Address

7. HEALTH & EDUCATION

Medical Conditions/Allergies

Physically Challenged

Type:

Currently Schooling

School Name

School Phone

8. DECLARATION

I declare that the information provided is true and correct. I agree to abide by church rules and regulations.

Receive Email Updates

Receive SMS Updates

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Date

Signature / Thumbprint

FOR OFFICE USE ONLY

Member ID

Date Received

Approved By

Date Approved

Remarks

Signature/Stamp