CWJC/CMJC Registration of Intent Form

Registration of Intent Form

Nationally Registered Site Application
Please note: This is a form to request registration as a CWJC/CMJC site. Once this form is complete, an endorsement form will be sent to your state's CWJC/CMJC coordinator. Once that is received in our office, you will be sent a payment link for $50 to complete your registration.
Date*

MonthDayYear
Date
Site Type*

CMJCCWJCCMJC & CWJC
Site Information
Site Name*
Site Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Site Phone Number*

Area CodePhone Number
Site's Primary Email*
example@example.com
Fax Number

Area CodePhone Number
Site's Web Address
Is this site a satellite site of an existing CWJC/CMJC Ministry?*

YesNo
If this is a satellite site, please provide the name of the existing site.
Site Coordinator Information
Name*

First NameLast Name
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Date and Location of NCT Completion*
Co-coordinator/Assistant Co-coordinator Information
Which type of Co-coordinator does your site have, if any?

Co-coordinatorAssistant Co-coordinatorNo Co-coordinator position/position is not filled
Name

First NameLast Name
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Date and Location of NCT Completion
Is there already an existing CWJC and/or CMJC site in your community?*

YesNo
If there is already a site in existence in your community, National WMU asks that you develop a covenant/agreement with them that states how you will work collaboratively with each other. Please upload that document below.

Browse Files

Cancelof
I acknowledge that, understanding the eight key elements, it is my intent to develop a CWJC/CMJC site. I also understand that my site must apply for national certification after we begin serving participants. I also agree with the CWJC/CMJC Statement of faith that is provided in the CWJC/CMJC Manual. In addition, I understand this is an application, and my registration is pending approval by National WMU.*

Clear
Site Coordinator E-Signature
Date*

MonthDayYear
Date
I acknowledge that, understanding the eight key elements, it is my intent to develop a CWJC/CMJC site. I also understand that my site must apply for national certification after we begin serving participants. I also agree with the CWJC/CMJC Statement of faith that is provided in the CWJC/CMJC Manual. In addition, I understand this is an application, and my registration is pending approval by National WMU.

Clear
Co-coordinator/Assistant Site Coordinator E-Signature
Date

MonthDayYear
Date
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