First Name     Last Name 

Address:  Street    City:   State:  Zip:

Date of Birth:

Telephone: (day)   (evening)

                     (Cell)   E-mail: 

Profession:   Licensed or Certified:  Yes No

Institutional Affiliation:

Referred/Invited By: 

Next of Kin:    Relationship:  

Previous Training in Religion:    

Briefly state how you see RCWM Churches meeting your needs:

Identify your areas of interest:  Redemption Community World Ministries

                                                          Redemption Institute of Theology

                                                          Redemption Quality of Life Centers

Membership oath: I by the grace of God willingly accept membership of Redemption Community World Ministries, Inc.  I agree to abide by the Church’s Statement of Faith and the principles for which the Church stands. I further agree to indemnify RCWM against any unauthorized actions on my path, including legal fees, court cost or other damages that may arise from such wrongdoing.

Branch:

Branch Location: 

Signature of prospective member:  Date:

OFFICE USE ONLY

Signature of RCWM personnel: ________________________        Title  Dir. of Membership Development