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  
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Home Phone Number:  
Work Phone:  
Cell Phone Number (If any):  
Email Address (If any):  
Social Security Number:  
Date of Birth:  
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.)  
By inputing my name in the input field below, I affirm that the information I have given is true and correct.
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