Please fill in the information below.   Only names, address, and phone number will be printed in directory.  All other information is for office use only.                   

Last Name___________________________________________________       

Address/City/State/Zip________________________________________________________

Phone # ____________________________________________

Name ________________________________Birth date__________________ � Baptized

Profession of Faith: where ______________________________ Date:_________________

Spouses Name _________________________Birth date__________________ � Baptized

Profession of Faith: where ______________________________ Date:_________________

� Single     �  Married: Anniversary date __________________________        � Divorced                        

Children ______________________________Birth date_________________ � Baptized

Profession of Faith: where ______________________________ Date:______________

_______________________________ Birth date_________________ � Baptized

Profession of Faith: where ______________________________ Date:______________

_______________________________ Birth date_________________ � Baptized

Profession of Faith: where ______________________________ Date:______________

_______________________________Birth date__________________ � Baptized

Profession of Faith: where ______________________________ Date:_______________

e-mail______________________________________________                        � listed

                                                                                                                               � not listed

Cellphone # __________________________________________                      � listed

Cellphone # __________________________________________                      � not listed

�  I do not want my family picture on the NLCC website.

Print off and  return to the clipboard on the Welcome Center, drop off at the NLCC office, or cut and paste into nlcc@iw.net. Thanks!

�  I do want my family picture on the NLCC website.