Become a Member

Member/Envelope #
Date*
MM slash DD slash YYYY
Name*
First Last
Family Role*
- Head of Household
- Spouse
- Child
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Work Phone*
Cell/home Phone*
Email*
Enter Email Confirm Email
Marital Status*
- Married
- Divorced
- Widowed
- Single Parent
- Single
Gender:*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY
Joined EMBC by:*
- Baptism
- Christian Experience
- Letter
- Watchcare
- Reinstatement
Emergency Contact*
First Last
Emergency Contact Relationship*
Emergency Contact Phone Number*
Ethnicity*
- African American
- Caucasian
- Hispanic/Latino
- Asian
- Native American
- Other
Military Service*
- ACTIVE DUTY
- RETIRED
- VETERAN
- Army
- Air Force
- Navy
- Marines
- National Guard
- Coast Guard
- Other
Current Occupational Category*
- IF YOU ARE A BUSINESS OWNER PLEASE CHECK HERE
- Retired
- Unemployed
- Administration
- Artist
- Civil Servant/Govt
- Craftsman/Laborer
- Education
- Entertainment
- Finance
- Homemaker
- IT
- Law Enforcement
- Legal
- Marketing/Design
- Medical
- Ministry or Church Related
- Real Estate
- Student
- Other
Highest Education Level*
- Less Than High School
- High School
- Some College
- Associates Degree
- Bachelors Degree
- Masters Degree
- Doctoral Degree
- Prof. Certificate
- Vocational Certificate
Languages Spoken/Written: (OTHER THAN ENGLISH)*
Medical/Disabilities/Other Needs:*
Special Skills, Training or Interests You Would Like To Share With Emmanuel:*
YOUR CHILDREN (Under the age of 18 years) #1
First Last
Gender
- Male
- Female
Ethnicity
Envelope # (if applicable)
YOUR CHILDREN (Under the age of 18 years) #2
First Last
Gender
- Male
- Female
Ethnicity
Envelope # (if applicable)
YOUR CHILDREN (Under the age of 18 years) #3
First Last
Gender
- Male
- Female
Ethnicity
Envelope # (if applicable)
YOUR CHILDREN (Under the age of 18 years) #4
First Last
Gender
- Male
- Female
Ethnicity
Envelope # (if applicable)
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North Campus

3615 Vickers Drive Colorado Springs, CO 80918
719-635-4865 ext. 110

South Campus

1 South Walnut St Colorado Springs, CO 80905
719-375-0814