Disaster Relief Member Profile

Charleston Baptist Association Disaster Relief Registration
	User Name:
	Password:
	Confirm Password:
		Southern Baptist Disaster Relief
		Personal Information Update
	First Name:		Middle Name:		Last Name:
	Address:
	City:			State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon Outside US/Canada	Zip:
	SSN:		Email:
	Church:		Association: Aiken Allendale-Hampton Barnwell-Bamberg Beaverdam Broad River Carolina Charleston Chester Chesterfield Colleton Columbia Metro Edgefield Edisto Florence Greenville Greer Kershaw Lakelands Laurens Lexington Marion Moriah North Greenville North Spartan Orangeburg-Calhoun Palmetto Pee Dee Pichens-Twelve Mile Piedmont Reedy River Ridge Saluda Santee Savannah River Screven Southeast Spartanburg County Baptist Network Union Waccamaw Welsh Neck Williamsburg Woodruff York
	Amateur Call Sign:		License Class:
	Whom to notify in case of Emergency:
	Name:		Relationship:
	Phone:
	Are you allergic to any medication?:		If So What?
	Health Insurance Carrier:		Policy or Group Number:
	Auto Insurance Carrier:		Auto Policy Number:
	Vehicle License Plate Number:
	Release and Indemnity Agreement
	Having fully read the Release and Indemnity Agreement on the other side of this form. This waver, release and indemnity agreement is fully understood by me and I enter the same willingly for the purposes herein stated.
	Witnesseth, my hand on this date of #CreateODBCDateTime(NOW())#
						Form SCDR1