Step 1 of 6 16% Last Name*This is the last name of the family for which you are filling in the form. It is also the last name that you'd like to have in the Church's directory.Your First Name*Your Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Your Email AddressChildren's Email Addresses (Optional)Please enter the email addresses of any of the children or dependents in your household to whom you'd like email correspondence from the church sent.PERMISSION TO EMAIL*Yes!No thanks.May we have your explicit permission to send emails relating to events and happenings at our church to the email addresses that have you entered on this form? You may withdraw permission for any or all addresses at any time by sending an email to: communications@brontesda.comHome PhoneYour Mobile PhonePERMISSION TO TEXT*Yes!No ThanksIn 2017 we hope to start a new communication initiative that involves the use of text messages. Texting is an excellent way for us to communicate with each other and offers us the ability to automate sending out things like event reminders or last-minute announcements to the members of our church. We hope that you will participate. You may withdraw permission at any time. Incoming text messages may carry a very small cost based on your mobile phone provider. AddressPlease enter the address that you'd like to have listed in the Church directory as your home address. Ex: 5090 Johnson Road, Burlington, L9T 6L5 Are you married?*YesNoAnniversary Date Date Format: MM slash DD slash YYYY Spouse's First NameLeave blank if unmarried.Spouse's Last Name (if Different)BirthdayMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Tick if person is NOT a member of Bronte Seventh-day Adventist Church Not a member Spouse's Mobile Phone NumberSpouse's Email Address CHILDREN - SAME LAST NAMEDo you have children who live at your address and that share your last name?*YesNoChild #1: First NameBirthdayMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child #1: Mobile Phone NumberPlease don't sign up for text messaging No text messages please Tick if person is NOT a member of Bronte Seventh-day Adventist Church Not a member Child #2: First NameBirthdayMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child #2: Mobile Phone NumberPlease don't sign up for text messaging No text messages please Tick if person is NOT a member of Bronte Seventh-day Adventist Church Not a member Child #3: First NameBirthdayMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child #3: Mobile Phone NumberPlease don't sign up for text messaging No text messages please Tick if person is NOT a member of Bronte Seventh-day Adventist Church Not a member Child #4: First NameBirthdayMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child #4: Mobile Phone NumberPlease don't sign up for text messaging No text messages please Tick if person is NOT a member of Bronte Seventh-day Adventist Church Not a member Child #5: First NameBirthdayMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child #5: Mobile Phone NumberPlease don't sign up for text messaging No text messages please Tick if person is NOT a member of Bronte Seventh-day Adventist Church Not a member CHILDREN - DIFFERENT LAST NAMEI have one or more children who go by a different last nameYesNo, we all share the same last nameChild #1 - First NameChild #1 - Last NameBirthdayMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child #1 - Mobile Phone NumberPlease don't sign up for text messaging No text messages please Tick if person is NOT a member of Bronte Seventh-day Adventist Church Not a member Child #2 - First NameChild #2 - Last NameBirthdayMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child #2 - Mobile Phone NumberPlease don't sign up for text messaging No text messages please Tick if person is NOT a member of Bronte Seventh-day Adventist Church Not a member Child #3 - First NameChild #3 - Last NameBirthdayMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Child #3 - Mobile Phone NumberPlease don't sign up for text messaging No text messages please Tick if person is NOT a member of Bronte Seventh-day Adventist Church Not a member OTHER FAMILY MEMBERSAre there other family members living at your address that you'd like to have included in the Church Directory?*YesNo thanks!Other Family Member #1 - First NameOther Family Member #1 - Last NameBirthdayMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Tick if person is NOT a member of Bronte Seventh-day Adventist Church Not a member Other Family Member #2 - First NameOther Family Member #2 - Last NameBirthdayMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Tick if person is NOT a member of Bronte Seventh-day Adventist Church Not a member Other Family Member #3 - First NameOther Family Member #3 - Last NameBirthdayMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Tick if person is NOT a member of Bronte Seventh-day Adventist Church Not a member NotesUse this area to add notes about this entry PERMISSION TO USE IMAGESWe hope that you will grant us permission to use photographic or video imagery taken of you and your family members in media like our website, social media and digital or print advertising. We will never use an image in a way that is inappropriate or not in line with the values of our church. You may withdraw permission at any time. You may also view the full policy on image usage on our church's website. www.brontesda.com PERMISSION TO USE IMAGES*Yes, you may use images of me, my spouse and any children under the age of 18 added under my householdYou may only use images of meNo, you may not use images that feature me, my spouse or children added under my household that are less than 18 years oldCommentsThis field is for validation purposes and should be left unchanged.
