Name *

First Name

Last Name

Your Birthday *

MM

DD

YYYY

Include birthday year in directory? *

Yes

No

Spouse's Name

First Name

Last Name

Spouse's Birthday

MM

DD

YYYY

Include Spouse's birthday year in directory?

Yes

No

Anniversary

MM

DD

YYYY

Allow email to be published? *

Yes

No

Allow spouse's email to be published?

Yes

No

Please include me in the Prayer Requests emails. *

Yes

No

Home Phone *

(###)

###

####

Mobile Phone (if you don't have a mobile phone, just reenter your home phone) *

(###)

###

####

Mobile phone published in directory?

Yes

No

Spouse's Mobile Phone

(###)

###

####

Spouses mobile phone published in directory?

Yes

No

Allow texting to mobile phone? *

Yes

No

SPAM PROTECTION: *

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