Church Information

Please complete this brief form in order to register as a CHEN member congregation. We thank you for becoming a part of this organization!

*Please enter the information of the Faith Leader in this section*

Title & First Name *

Last Name *

Position (e.g. Pastor, Associate Minister, etc.) *

Gender *

Male

Female Female

Phone Type *

Phone Number *

Email Address *

Church Name *

Church Street Address *

Address Line 2

City *

State *

Zip Code *

Approximate Membership #

Health Liaison Information

Please review the information below on the role of the Health Liaison within your congregation. Then provide the information for the member who will assume the role in the fields below.

Same as above? (If yes, you may submit the form now) *

Yes

No

Title & First Name

Last Name

Position (if applicable)

Gender

Male

Female Female

Phone Type

Phone Number

Email Address