My Next Step Today*:
(check all that apply)

I want to accept Jesus Christ as my Savior.I would like to be baptized.I would like to become a member of Green Valley.I would like to talk to a ministry team member.

Today's Date:

Full Name*:

Name you go by:

Gender:
MaleFemale

Marital Status:
SingleEngagedMarried

Date of Birth:

Cell Phone:

Home Phone:

Email:

Permanent Address:

Temporary/College Address:

Occupation:

Place of Employment:

Choose one of the following:
I have never been a member of a church before.I am currently a member of a church (list church below)I wasn't a member, but I formerly attended a church (list church below)

Church Name:

Have you been baptized by immersion?:
yesno

Also living at my home:
Please give name, DOB, grade, age and school attended by children (if applicable) and relationship to you.

Δ