New Ebenezer Baptist Church                                                                                                                                                                  HEALING HEARTS MEMBERSHIP INTAKE FORM

Please respond to the areas below and email back to healingheartsmnebc@gmail.com Individual’s Name: ______________________________________________________    Date: ___________________Contact InformationAddress: ________________________________________________________________________________________Contact Number(s): _______________________________________________________________________________Birthday: ______________________             Are You a Member of New Ebenezer Baptist Church?  YES____/ NO____Why Would You Like to Join the Healing Hearts Ministry? ______________________________________________________________________________________________________________________________________________________________________________________________Anything Else You Would Like to Share:_______________________________________________________________________________________________Any Ideas/Projects You Would Like to see HHM Sponsor?______________________________________________________________________________________________________________________________________________________________________________________________Person Receiving Information: ___________________________________________    Date: _____________________