PROSPECTIVE MEMBER
INFORMATION FORM

Last Name  First Name  Middle

Title    Phone   Marital Status

Date of Birth (MM/DD/YYYY)     

Email Address

Name for Church Roster

Name for Name Badge

Mailing Address  Apt./Unit #

City  State  Zip

It is my desire to unite with Valley Presbyterian Church by: 

PROFESSION OF FAITH - if you have never been baptized
REAFFIRMATION OF FAITH - if you have been baptized and/or were at one time a member of a church, but
                                            are now inactive.  (*Please provide name of church, address, etc., below.)
CERTIFICATE OF TRANSFER - if you have been baptized and are not an active member of a church.  (*Please
                                             provide name of church, address, etc., below.)
AFFILIATE - If you are an active member of another church, but a temporary resident in this community; e.g.,
                   winter resident, military, or college student.  (*Please provide church name, address, etc., below.)

*Name of Church  Address
         City/State         Zip

I am a former member of Valley Presbyterian Church

The following are members of my family:  (list yourself, spouse and children who live with you.)

Name  Birthdate    
         Preferred Name        City/State of Birth   
         Date/Place of Baptism  Not Baptized
Name  Birthdate   
        Preferred Name         City/State of Birth   
         Date/Place of Baptism  Not Baptized
Name  Birthdate   
         Preferred Name        City/State of Birth   
         Date/Place of Baptism  Not Baptized
Name  Birthdate   
         Preferred Name        City/State of Birth   
         Date/Place of Baptism  Not Baptized
Name  Birthdate   
         Preferred Name        City/State of Birth   
         Date/Place of Baptism  Not Baptized

Name  Birthdate   
         Preferred Name        City/State of Birth   
         Date/Place of Baptism  Not Baptized

Emergency Information

Physician Name/Telephone

Nearest Relative (not living with you) we can contact in an emergency:
Name  Phone  
Address  City/State/Zip

Occupation (Past/Present)  Firm
Business Phone     Retired

Have you ever been ordained an elder or deacon in the Presbyterian Church?  If yes:
Elder:
Church  City/State  Dates

Deacon:
Church  City/State   Dates

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