Contact Information for Southport Christian Church
For Everyone in Your Household over the age of 18
Email address
ENTER INFORMATION ABOUT YOURSELF
Full Legal Name
We need your legal name in order to locate you in the hospital or other health care facility.
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Name You Go By
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Street Address
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City
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Zip Code
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Email Address We Have Permission to Use
SCC uses email for our weekly E-News and for urgent communications and prayer requests.
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Alternate Email Address We Have Permission to Use
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Do you have a landline?
Landline Phone Number (with area code)
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Your Cell Phone Number
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Alternate Cell or Business Phone Number
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Emergency Contact (1)
Please enter the name and phone number of your first emergency contact.
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Emergency Contact (2)
Please enter the name and phone number of someone who does not live with you.
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Do you have any allergies or health concerns we need to know about?
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Please enter your birthday
Month and day, year if you want to!
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Do you have relatives who attend SCC?
"Relatives" refers to those outside of your immediate family.
Please list relatives here.
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