About you *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile Phone *

(###)

###

####

Birthday *

MM

DD

YYYY

Marital Status *

Single

Married

Widowed

Co-habitating

Divorced

Re-married

Have you accepted Jesus Christ as your Lord and Savior? *

Yes

No

Not sure

Are you a member at Five Rivers Church? *

Yes

No

Are you full-time or part-time

Full-time

Part-time

Do you use tobacco (i.e. smoke, chew, etc)? *

Yes

No

Have you used illegal drugs in the past year *

Yes

No

Have you participated in any illicit sexual activity in the past year?

Yes

No

Do you drink? *

Yes

No

Do you watch R-rated movies *

Yes

No

Have you ever been convicted of or plead guilty to a crime? *

Yes

No

Is there any circumstance, or pattern of thought or behavior in your life that would make it inappropriate for you to work with minors at Five Rivers Church? *

Yes

No