Name (First, Last)

E-mail address

Mailing address

City, State, Zip

Phone (xxx)xxx-xxxx

Today's Date
(mm/dd/yyyy)

Select from the pop-down menu the option that best describes your status
--Click here for selection menu-- *Retain my membership; I am actively looking for another church to join as soon as possible. *Retain my membership; I am currently in process of joining another church; check back in a few months. *Retain my membership due to special circumstances which I will explain in the comments below (military, school, etc.) *Retain my membership; I plan to resume regular attendance and participation in the life of Grace Church (PCA). *Remove my name from the Grace roll since I have joined and am a member of another church. *Remove my name from the roll because I don't plan to resume participation at Grace, nor do I plan to join another church. *Other (explain in comments below)

Other Comments - Special Notes (special reasons unable to attend or for membership retention)

If you have joined (become a member) of another church, please provide the church name and address.

I would like to request a visit from a pastor/elder.
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