Charter Application

PO Box 211866 Bedford, TX 76095 | 817.554.5900 ext:352 | impact@pcg.org | www.impactym.com

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Date Date / MM / DD YYYY
Name of District
Name of District Youth Director Name of District Youth Director First Last
Name of Church
Address of Church Address of Church
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Church Phone Number Church Phone Number - ### - ### ####
Pastor's Name Pastor's Name First Last
Church Website
Average Church Attendance
PCG Church

PCG Church Yes No
Fellowship Church

Fellowship Church Yes No
Youth Group's Name
Youth Pastor/ Youth Leader's Name Youth Pastor/ Youth Leader's Name First Last
Youth Leader

Youth Leader Full time Part time
Youth Leader

Youth Leader Paid Staff Volunteer Staff
Youth Leader Phone Youth Leader Phone - ### - ### ####
Youth Leader Email
Youth Leader Address Youth Leader Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Number of Children ages 6-12
Number of Students ages 13-20
Pastor's Signature

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
By Checking Yes I understand that I have spoken with the District Youth Director in my respective District and I have his/her permission to Charter my group

By Checking Yes I understand that I have spoken with the District Youth Director in my respective District and I have his/her permission to Charter my group Yes No Please help me get in contact with my respective DYD
Method of Payment

Method of Payment Check (see instructions below) Credit Card (will be redirected to payment screen)
If writing a check, please make it out to "IMPACT PCG" for the amount of $50 and please mail it to: IMPACT PCG PO Box 211866 Bedford, TX 76095

Charter Application

Charter Application

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Total

If writing a check, please make it out to "IMPACT PCG" for the amount of $50 and please mail it to: IMPACT PCG PO Box 211866 Bedford, TX 76095

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