Minister Information Form

Christian Church (Disciples of Christ) of Mid-America
Minister Information Form

Welcome to the Christian Church (Disciples of Christ) of Mid-America! As a new or returning Minister to the Mid-America Region, please complete this Information Form to ensure your clergy records are updated with accurate information.

Should you have any questions, please contact your Ministry Associate in the Springfield Regional Office at sgf@ccmadisciples.org. Thank you so much!
Date:

MonthDayYear
Date
Title:
Name:

First NameMiddle NameLast Name
Preferred First Name:
Email Address:
example@example.com
Cell Phone Number:
Please enter a valid phone number.
Work Phone Number (if applicable)
Please enter a valid phone number.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth:

MonthDayYear
Date
Gender
Please use this field at your own discretion.
Ethnicity
Please use this field at your own discretion.
Pronouns
Please use this field at your own discretion.

New/Current Place of Employment (Ministerial Site):
The Name of your Congregation/Organization/Institution. If you are Retired, please specify "N/A-Retired."
Address of New/Current Ministerial Site:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position/Title at New/Current Ministerial Site:
Please Note: If you are Retired, please leave blank.
Begin Date at New/Current Ministerial Site:

MonthDayYear
Please Note: If you are Retired, please leave blank.
Previous Place of Employment (Ministerial Site):
if applicable
Address of Previous Ministerial Site:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Ministerial Site Position/Title:
Begin Date for Previous Ministerial Site:

MonthDayYear
Date
End Date for Previous Ministerial Site:

MonthDayYear
Date
Are you Bi-Vocational?

YesNoOther
Position/Title Held for Secondary Employment
Name of Congregation/Organization/Institution for Secondary Employment
Type a question
Are you Volunteering anywhere? (To better understand the full scope of your Ministry.)

YesNoOther
Your Position/Title as a Volunteer
Name of Organization/Institution where you Volunteer
Begin Date for Volunteer Position
Comments/Additional Information (if applicable)
Anything else that may be considered helpful for record-keeping purposes.
Additional Files/Documents (if applicable)

Please upload any additional files/documents that you would like stored in your Mid-America Regional clergy file.
Cancelof
The information contained in this form is true and accurate as best my memory serves me.

Clear
Should be Empty: