Marketplace Discipleship Application Page 1 (HIPPA Compliant)

Marketplace Discipleship Application
Email *
example@example.com
Name *

First Name Last Name
Phone Number *
Birthday *

Month Day Year
Date
Gender *

Male Female
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Marital Status *
Do you have minor children *

Yes No
Will your children be attending with you? *

Yes No
Education Information
Highest Level of Education Completed *
What languages do you speak? *
(most fluent to least)
Work Experience
What is your current occupation? *
Please list one to two professional goals. *
Please give an example of a time you faced a challenge in your workplace and overcame it. What did you learn from the experience? *
Passport Information

Attention: Outreach locations are almost always outside the United States, so you will need a passport to travel. Please check if your passport is still valid 9 months after the first day the discipleship program begins, and please renew it if it is not.
Country of Birth *
Country of Citizenship *
Do you hold a valid passport *

Yes No
Passport Expiration Date *

Month Day Year
Date
Finance Information
Do you have the total fees for your lecture and outreach *

Yes No
How much do you have? What is your plan to raise the remainder of the fees? *
Church Information
Do you currently attend a church? *

Yes No
How long have you been attending your church? *
Are you active in church (i.e. attending small group, serving in the worship team, etc.)? Please explain. *
Reference Information

Please do NOT list family members or significant others as references.
Reference Full Name *
First and Last Name
Reference Phone Number *
Reference Email *
Relationship to Applicant *
EX) Pastor, Leader, or Mentor
Personal Questions
When and how did you decide to follow Jesus? *
Please note, sensitive information should not be included in this response.
Why would you like to attend the Marketplace Discipleship Movement? *
Please note, sensitive information should not be included in this response.
How would you describe your current relationship with God? *
Please note, sensitive information should not be included in this response.
How is your relationship with your family? How do they feel about your involvement in the program? *
Please note, sensitive information should not be included in this response.
What do you hope to learn and/or gain in a discipleship school for people in the workplace? *
How do you see (or how would you like to see) your professional goals intersecting with living on mission and building God's kingdom? *
Please list three spiritual strengths/gifts and three professional strengths. *
Please list three desired spiritual areas of growth and one desired professional area of growth. *
Contact Owner *
Lead Status *
Submitted Marketplace Application *
Should be Empty:

Marketplace Discipleship Application

Education Information

Work Experience

Passport Information

Finance Information

Church Information

Reference Information

Personal Questions