Empowered Cohort Participant Information Form
SNEMN Credentialed Women's Leadership Cohort
Please share following information:
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthdate
*
-
Month
-
Day
Year
Date
Phone Number
*
E-mail
*
example@example.com
Name of Church
*
Church - City and State
*
Name of Pastor
*
What level of credentials do you hold?
*
Ordained
Licensed
Certified
Local Church License
In process - paperwork is in
Interested in becoming credentialed
Not interested in becoming credentialed
Are You:
Paid Staff
Volunteer
Paid Full-Time
Paid Part-Time
Bi-Vocational
Are You:
Paid Staff
Volunteer
Paid Full-Time
Paid Part-Time
Bi-Vocational
What is your financial plan to pay for your participation in the Cohort
*
I will pay full amount of $1,200.00 in August
My church will be paying the full amount of $1,200 in August
I will be making 10 monthly payments August - May of $120 per month for a total of $1,200
None of the above - I have made arrangements and will describe in the next section.
Describe your arrangements here
What ministry are you involved in currently:
*
What are you hoping to be the outcome of your participation in the Cohort?
*
Please provide the names, email addresses and phone numbers of 3 references. (your lead pastor, another credential holder, and a personal friend/colleague)
Do we have your permission to contact your references?
YES
NO
Submit
Should be Empty: