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Max Cleland

If you are interested in becoming a member of Antioch-Lithonia, please fill out the following membership form.

First name:*

Last name:*

MI:

Preferred Name:

Birth Date:*

Gender:

Male

Female

Address

Street Address:*

Street Address 2:

City:*

State:*

Zip:*

Phone & Email

Primary Phone:*

Primary Phone Type:

Home

Mobile

Alternate Phone:

Alternate Phone Type:

Home

Mobile

Publish Number in Church Directory:

Yes

No

Email:

Emergency Contact(s) - Name & Number:

Family/Household

Marital Status:

Single

Engaged

Married

Separated

Divorced

Widowed

Family/Household (Please list each Name, DOB, and Relationship):

Church Membership

Joining with Christian Experience?

Want to Be Baptized?

Ministries/Departments You Are Interested In (select all that apply)

Academic & Cultural Enrichment (ACE)	Benevolence/ Outreach	Christian Education
College	Couples	Mass Communication
Mature Adults	Media	Men's
Ministerial	Nurses	Nursery
Personal Support & Development (PSD)	Recreation	Senior Ministry (NTO's-Never Too Old)
Singles	Teens	Women's
Worship & Performing Arts (choir/dance/drama)	Worship Support (Ushers & Greeters)	Youth

Other Information

Occupation(s):

Employer(s):

Allergies/ Medical Conditions:

Hobbies Talents & Other Interests:

Past Church Activities/Offices/Committees (if applicable):

Additional Comments:

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"God's grace and mercy allowed us to be the greatest church in the universe." ~Pastor Ward

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Antioch-Lithonia Missionary Baptist Church
2152 Rock Chapel Rd. | Lithonia, GA 30058 | PH: (770) 482-1277| FAX: (770) 482-1584

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