Email: __________________________________________

Address: _____________________________________________________________________

Daytime Telephone:  _____________  Evening:  _______________

Work:   Full Time _____    Part Time  _____

Any special gifts or talents:  _______________________________________________________

____________________________________________________________________________

____________________________________________________________________________


Brief comments of any ideas for outreach:  ____________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Special Interests:  _______________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Annual Membership Fee:  $19.95

Send to: 
Ministry of the Bleeding Heart
P.O. Box 505
Lewisville, NC 27023