See A Man Be A Man (SAMBAM)
 
  Mentoring program of Board of Men's Ministries;
Church of Christ of the Apostolic Faith;
Jesse L. Gamble, Mentoring Program Chairman;
Ernest Walker, Director/Chairman;
District Elder Eugene Lundy, M.D., M.B.A., D.D., Pastor
 
   
:: Adult Application / Registration ::
 
   
*Click Here for the mailable, printer-friendly version  
(Requires Adobe Acrobat Reader)


 
   
Name:  
   
Address:  
   
City:  
   

State:

 
     
Zipcode:  
   
Home Phone Number:  
     
Work Phone:  
     
Cell Phone Number (If any):  
     
Email Address (If any):  
     
Social Security Number:  
     
Date of Birth:  
     
Occupation:  
     
Employer and Business Address:  
     
Driver's License No.:  
     
Designated State:  
     
Driver's License Expiration:  
   
Emergency Contact Name:
 
     
Emergency Contact Phone:  
     
Your experience in working with youth:  
     
     
:: Additional information ::
     
Do you use illegal drugs? Yes. | No.
 
Have you ever been convicted of a criminal offense?
Yes. | No.
(If yes, explain.)  
 
Have you ever been charged with child neglect or abuse?
Yes. | No.
 
Has your driver's license ever been suspended or revoked?
Yes. | No.
 
Any fact or circumstance involving you or your background that would call into question your being entrusted with the supervision, guidance or care of young people?
Yes. | No.
(If yes, explain.)  
     
Reference:  
 
By inputing my name in the input field below, I affirm that the information I have given is true and correct.
Name:  
Date:  
     
     
 
 
   
   
 
 
   
   
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