Name:

Home Address:

City:

State:

  Zip:

Phone:

E-mail:

Church Name:

Church Address:

City:

State:

  Zip:

Are you a former Ambassador?  
    Yes No

   If so, for how long?  

Outreach/ministry programs the church is involved in:

Outreach/ministry programs you are personally involved in within the church:

Referred by (optional):

In 50 words or less, please tell us why you want to be an LHM Ambassador:

I am applying to replace an Ambassador

If you are applying to replace an Ambassador, please complete the following:

Former Ambassador Name:

Home Address:

City:

State:

  Zip:

Phone: