Assessment Registration

My Name*

First Last

My Email*

My Mobile*

Home Address

Street Address City State ZIP Code

Current Marital Status*

My Current Job Title

Years in My Current Job

My Spouse's Name*

First Last

My Spouse's Email*

My Spouse's Mobile*

My Spouse's Current Job Title

Spouse's Years in Current Job

What dietary restrictions and/or food allergies do either you or your spouse need accommodated:*

What denomination or fellowship of churches (if any) would you consider yourself associated with?*

Which Network(s) are you planting with?*

If you are currently being considered for a specific church plant project, please provide the location of the project and your role:*

I’m not sure

Other

Who will come with you to the event as your sponsor?*

First Last

Sponsor's Email*

Sponsor's Mobile

Which congregation are you currently a member of?*

Church of Membership Location

City State / Province / Region

Payment Amount*

$300 Deposit to Save My Seat

$1,600 Full Payment

Coupon Code

Ask for the $100 Earlybird Coupon valid thru April 12 by emailing planting@church-planting.net

Credit Card

Total