E-Member Registration

First Name *

Last Name *

Date of Birth *

Marital Status *

Email Address *

Phone Number *

Occupation *

Home Address *

Number of Children Under 18: *

Would you like to opt-in to receive e-mail notifications? *

How did you hear about us? *

If you selected "OTHER" please let us know how you heard about us below:

CHECK BOX *

understand that my attendance to New Member's Orientation is required to become an eMember at Rehoboth Ministries.

Date of Form Completion: *