Returning Student Registration Form

Name *

First

Middle

Last

Email *

Please enter your email, so we can follow up with you.

Student Attendance Plan *

Address

Address Line 1

Address Line 2

City

State

Zip Code

How long at this address in years?

Mobile Phone *

Home Phone

Work Phone

Name of Emergency Contact *

First

Last

Emergency Contact Phone

Emergency Contact Relationship

Emergency Contact Email

Is Redemption House Life Center your home church?

If not, where do you attend church?

What are your spiritual passions?

In what capacity are you currently serving?

Tell us about your experiences with healings, miracles, signs, and wonders.

Birth Date

Gender

Race

Are you of Hispanic or Latino origin?

Nation of Birth

Citizenship

Nation of Citizenship