MEMBERSHIP FORM

Name:	___________________________________
Address:	___________________________________
Phone:	___________________________________
E-mail:	___________________________________
Birthdate:	___________________________________

Yes, I want to sign up for a free MEMBERSHIP.
Indicate any programs you may be interested in getting involved with:
_____ Missions Support
_____ Service Projects
_____ Fellowship (group rides/trips/activities)
_____ TEAM Pistis
_____ Leadership and/or fundraising activities

I allow PISTIS to use any photos /videos of me for publicity and promotions. I am aware of the inherent risks of the activities involved with PISTIS and I release PISTIS Ministries from any and all liability, and I will take full responsibility for any and all accidents and injuries which may be sustained.

Signature_________________________   Date:____________________

Send to: PISTIS Ministries 1561 SW Jordan Street Grants Pass, OR 97526

Phone: 541-659-4104 E-mail: dcjmccann@msn.com Tax id # 20-4510085

Enclosed is my contribution in the amount of $__________ for support with:
_____ General support for PISTIS Ministries
_____ Missions Support
_____ Service Projects
_____ Fellowship (group rides/trips/activities)
_____ TEAM Pistis