ChurchFamilyHealth.com

Family Health Assessment Registration Form
Family Health Assessment Registration Form * denotes a required field
Required	Full Church name:
Required	Denomination:
Required	Country: United States Outside of the United States
Required	Street Address:
Required	City:
Required	State:
Required	International State / Region:
Required	Zip: -
Mailing Address: Same as street address
Mailing Address:
City:
*State:
*State / Region:
Zip:

Required	Phone: () - -
	Fax: () - -

Church Contact
Required	First Name:
Required	Last Name:
Required	Title:
Required	Email: (where assessment results will be sent) (EX JohnDoe@aol.com)
Required	Confirm Email:
	Website:
Required	Year church was established: ( Must be Numeric )

Senior Pastor
Required	First Name:
Required	Last Name:

Required	Average weekly attendance of adults: ( Must be Numeric )
Required	Number of worship services per weekend: ( Must be Numeric )
Required	Number of paid staff: ( Must be Numeric )
Required	Total annual budget:
Required	How did you hear about this survey?:
Required	Date Survey will be available: Choose date
Required	Date Survey will be closed: Choose date
Each survey participant will see the following greeting and brief instructions prior to beginning the survey. Please take a moment to personalize the closing at the bottom (you may add/edit as you like). Welcome! Thank you for taking the time to participate in this survey. This exercise will help us get an honest appraisal of the family units in our church body. As a result, we'll know where we need to apply intentional focus and openness to God's continued shaping of our ministry. Please try to answer each question candidly and honestly. Your first reaction is usually best so try to move swiftly through the assessment without bogging down and overanalyzing your responses. This should take approximately 15 minutes to complete. Be assured that your responses will be kept strictly confidential and at no point will your name be associated with your responses. IMPORTANT: Do not use the browser's BACK button during the survey. Doing so may lock up your computer.
Gratefully in Christ, The Leadership Team [Your Church Name Here]
In order to keep your survey secure, please pick two separate passwords. One for your pastors and the other for your congregation. Don't worry, these will be emailed to you in a confirmation email.
Required	Pastor password:
Required	Congregation password:
Release of Data for Aggregated Research Your church's data will be combined into an international aggregate database of all churches that have participated in the assessment process. This database enables us to study macro level trends in denominations, generational categories, geographic regions, etc. All data will be kept strictly confidential. At no point will your individual churches data be singled out or made available to the public. We do not sell or share our mailing list.
Accept?

* denotes a required field

Church Contact

Senior Pastor