Membership Enrollment Form

Once you have completed this form, you will be taken to a page where you may pay the registration fee online by credit card or by check. Fee must be paid prior to membership activation.

Contact Information:

INFORMATION IN THIS COLUMN WILL NOT APPEAR IN YOUR PROFILE. IT IS FOR OUR OFFICE USE ONLY.

Your first and last name **

Your eMail Address **

Re-enter eMail Address **

Your phone number with area code **

Your mailing address, including city, state/province, postal code (for billing only)**

SIGN ME UP FOR:**
1 month membership: $20

3 month membership: $50 $35 special rate

6 month membership: $70 $45 special rate

12 month membership: $90 $65 special rate

REFERRED BY: If you were referred by a current ChristianScienceSingles.com Member, please type their name here:

Special instructions/questions

PHOTO(S) FOR YOUR PROFILE: Photos are optional. If you do not include your photo(s) our "sketchy heart logo" will appear in its place in your Profile.

Sending your photos: We prefer to receive your photos by eMail. We will size them here. Photos should be at least 350 x 500 pixels. Not sure what size they are? Send them to us anyway.

eMail your photos to us or mail it to: Prayerful Living Publishing, PO Box 74248, Phoenix, AZ 85087

Your Profile Information

The information below will be used to create your Member Profile.

What USERNAME would you like to use?**
[6-12 characters (letters/numbers) - lower case]

What PASSWORD would you like to use?**
[6-12 characters (letters/numbers) - lower case]

We will eMail you your password once your membership is activated. You will use your username and password to access the Members' Area and your Private Messages.

MY AGE GROUP: choose one**
20 - 29    30 - 39    40 - 49   
50 - 59    60+

FROM: give a general idea of where you are, like "state" or certain "metro-area" This will appear in your Member Profile AND in your Introduction on the public side of the site. **

MY INTRODUCTION: Sell yourself! This will appear in your Member Profile AND in your Introduction on the public side of the site. Keep it to 50 words.**

RELATIONSHIP I AM LOOKING FOR: What type of relationship are you looking for? a like-minded friend to talk to or eMail, someone to do things with, a more serious relationship, a marriage partner? etc. This will appear in your Member Profile AND in your Introduction on the public side of the site. **

QUALITIES OF THE INDIVIDUAL I AM LOOKING FOR: **

MY OCCUPATION / EDUCATION: **

CHILDREN: Mention if you have kids, if they live with you, if they are grown, etc.**

MY INTERESTS/HOBBIES: **

MY PERSONAL CHARACTERISTICS: personality, any physical attributes you'd like to mention, etc., focusing more on the "whole person" **

Once you have clicked the "submit" button below, you will be taken to a payment page with instructions on how to pay for your membership. We must receive payment before your membership will be activated and your profile created. Once we have activated your membership, we will email you with further instructions. Please allow up to 72 hours for us to set up your profile and account.

** required fields