Name *

First Name

Last Name

Age *

11-18

19-35

36-50

51+

I'd like to receive the weekly newsletter and other correspondence:

Yes

No

Are you a Christian?

Yes

No

Seeking a spiritual home?

Yes

No

How did you hear about CCIC?

Internet

Friend (please enter your friend's name in the "Additional Details" field at the end of this form)

Other (please let us know in the "Additional Details" field at the end of this form)

Please contact me about:

Prayer Request(s)

Church Group or Activity

God, Jesus, Studying the Bible, etc.

Children's or Youth Programs (please enter your child's age in the "Additional Details" field at the end of the form)

Other (please let us know in the "Additional Details" field at the end of the form)