Young People's Ministry Council Application
Please use this form to apply for membership in Susquehanna Conference Young People's Ministry Council.
General Information
Name *
Please enter your full First and Last Names.
Age Group *
Please Select Your Age Group.
High School Graduation Year *
Please Select Your High School Graduation Year.
Age
Please Enter Your Age.
Birth Date *
Please Enter Your Birth Date.
MM
/
DD
/
YYYY
Gender *
Please Select Your Gender.
Home Phone
Please Enter Your Home Phone Number.
Cell Phone
Please Enter Your Cell Phone Number.
Willing to Receive Text Messages? *
Are You Willing to Receive Text Messages?
Address *
Please Enter Your Home Street Address and P.O. Box (if applicable).
City *
Please Enter Your City.
State *
Please Enter Your State.
ZIP *
Please Enter Your ZIP Code.
Email *
Please Enter Your Email Address.
Local Church Name and City *
Please Enter the Name of Your Local Church and the City.
District *
Please Select Your District.
Local Church Pastor's Name *
Please Enter Your Local Church Pastor's Full Name.
Pastor's Phone Number *
Please Enter Your Local Church Pastor's Phone Number.
Next
Never submit passwords through Google Forms.
This form was created inside of Susquehanna Conference. Report Abuse