Church Membership | Registration

This form is to be filled out for EACH individual member of your family.
Are you the head of the household*
Relationship to the head of the household*
Household name*

Please enter a unique household name to identify your family/members and use this same name when filling out this form for your additional family members. Example: JChapman
Name*
Mr, Mrs, Ms, Miss, Dr, Rev First Middle Last Jr, Sr, Ph.D, I, II
Gender*
Date of Birth*
For privacy purposes, please select 1 for the day. Do not enter your real birth - "Day" Looking for an accurate Month and Year.
Marital Status*
Anniversary*
For privacy purposes, please select 1 for the day. Do not enter your real day
Date of Baptism
Medical Notes/Allergies
Please provide any medical notes or allergies the church medical team should be aware of in case of emergency.
Are you currently a student?*
Highest Level of Education
Degree Name/Title

Example: Bachelors in Information Science
Grade*
Select your current level of education
School Type*
School Name
Would you like to be subscribed to the Email Alerts notifications and/or the Distribution List?*
Email*
Enter Email Confirm Email
Would you like to be subscribed to the Voice Phone audio alerts notifications?*
Home Phone*
If you do not have a Home phone number, please list your Mobile phone number.
Work Phone
Would you like to be subscribed to the Text alerts notification?*
Mobile Phone*
516-516-5555
Cell Phone Carrier*
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Employment Status
Job Industry
Are you interested in Small Groups?*
Please read the consent below
Is the person listed above, above the age of 18?*
Consent*
I agree to the privacy policy and consent
RELEASE AND HOLD HARMLESS AGREEMENT

The undersigned hereby releases and forever discharges and agrees to hold harmless CORNERSTONE CHURCH, Pastor Finney Samuel, its and his heirs, executors, administrators, agents and assigns, and all other persons, firms or corporations liable or who might be claimed to be liable, none of whom admit any liability to the undersigned but all expressly deny any liability, from any and all claims, demands, damages, actions, causes of action or suits of any kind or nature whatsoever, and particularly on account of all injuries, known and unknown, both to person and property, which have resulted or may in the future develop from my right to provide my data and the data consent located at 343 Jerusalem Ave, Hicksville, NY, 11801, beginning on the day I submitted this online form, until its completion.
The undersigned hereby declares that the terms of this agreement have been completely read and are fully understood and voluntarily accepted for the express purpose of precluding forever any claims arising out of the aforesaid volunteer services.
IN WITNESS WHEREOF, I have hereunto set my hand this day I fill out this form.

------------------------------------------------------
SOCIAL MEDIA & WEBSITE

I, the undersigned, do hereby grant permission to Cornerstone Church, Inc. to post my and/or my child’s story, photo, or other item, hereinafter referred to as “Materials,” I submit to and for Cornerstone Church, Inc.’s Web site, Twitter account, Instagram, SnapChat and Facebook account.
I hereby release you, your representative, employees, managers, members, officers, parent companies, subsidiaries, and directors, from all claims and demands arising out of or in connection with any use of said “Materials”, including, without limitation, all claims for invasion of privacy, infringement of my right of publicity, defamation and any other personal and/or property rights.
I acknowledge and agree that no sums whatsoever will be due to me or the minor I am signing for as a result of the use and/or exploitation of the “Materials” or any rights therein.
------------------------------------------------------
PHOTO & VIDEO

Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to Cornerstone Church, Inc., its affiliates and agents, to use my image and likeness and/or any interview statements from me in its publications, advertising or other media activities (including the Internet). This consent includes, but is not limited to:

(a) Permission to livestream, interview, film, photograph, tape, or otherwise make a video reproduction of me and/or record my voice;

(b) Permission to use my name; and

(c) Permission to use quotes from the interview(s) (or excerpts of such quotes), the film, photograph(s), tape(s) or reproduction(s) of me, and/or recording of my voice, in part or in whole, in its publications, in newspapers, magazines and other print media, on television, radio and electronic media (including the Internet), in theatrical media and/or in mailings for educational and awareness.

This consent is given in perpetuity, and does not require prior approval by me with the Name & Address above and with a digital signature of a representative from the church.

If the (I am signing for a minor is checked), the below signed parent or legal guardian of the above-named minor child hereby consents to and gives permission to the above on behalf of such minor child.
Hidden
Date Submitted*
MM slash DD slash YYYY
Print Name*
Signed Person's Phone*
Relationship To minor listed in this form*
Signature*
BY DIGITALLY SIGNING THIS, YOU HAVE READ AND ACCEPTED THE CONSENT ABOVE
Parent or Legal Guardian Signature*
The above signed parent or legal guardian of the above-named minor child hereby consents to and gives permission to the above on behalf of such minor child. BY DIGITALLY SIGNING THIS, YOU HAVE READ AND ACCEPTED THE CONSENT FOR THE STATED MINOR ABOVE
Comments
This field is for validation purposes and should be left unchanged.

This form is to be filled out for EACH individual member of your family.

Please read the consent below