Become A Member – Global Impact Christian Ministries

Become a Member of GICM
Membership Requirements:
Are you born again?*
- Yes
- No
Have you ever been water baptized?*
- Yes
- No
Basic Information
Name*
First Last
Date of Birth*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Marital Status*
- Married
- Single
- Divorced
- Widow

Children (Under 18)

Name:	DOB	Allergies

If You Are Under 18 Please List Your Parents Names
How did you hear about us?*
- TV
- Billboard
- Internet
- Family/Friend
- Mail
- Books
- Newspaper
- Drive By
- Other