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CUMC Connection Card
Please complete this form so that we can update our member/visitor records
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* Indicates required question
Family Mailing Label
*
ie: Mr. & Mrs. Smith, Mrs. Bob Smith, Mrs. Sue Smith, Dr. Bob Smith, Bob & Sue Smith
Your answer
Family Home Address
*
Address, City, State, Zip Code
Your answer
Home Phone
*
Your answer
First Name
*
Your answer
Nickname
Your answer
Last Name
*
Your answer
Email Address
*
Your answer
Cell Phone
Your answer
Family Relation
*
Adult
Wife
Husband
Child
Gender
*
Female
Male
Birthdate
*
MM
/
DD
/
YYYY
Marital Status
*
Single
Married
Divorced
Separated
Widow
Marriage Date
MM
/
DD
/
YYYY
Is there a second adult in your household?
*
If there is not another adult in your household please continue on to the next question.
Yes
No, but I have children in my household
No, I live alone
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