Young People's Ministry Council Application

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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.

Youth

Young Adult

Adult

High School Graduation Year *

Please Select Your High School Graduation Year.

Age

Please Enter Your Age.

Birth Date *

Please Enter Your Birth Date.

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?

Yes

Not Applicable

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.

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