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* 1. Please enter your current contact information

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* 2. I am a/an:

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* 3. Please enter your current ministry setting information:

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* 4. This is a:

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* 5. Congregation in which your membership is maintained:

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* 7. Describe your involvement in ministry in your local church during the past year:

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* 8. Describe your involvement in ministry in the Regional church during the past year:

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* 9. Describe your involvement in ministry in the General church during the past year:

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* 10. Describe your involvement in ministry in the Ecumenical  church during the past year:

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* 11. Describe your involvement in teaching ministry in higher education, various forms of chaplaincies, pastoral counseling, or other activities that are recognized as ministry by the Christian Church (Disciples of Christ) .

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* 12. The practice of ministry involves participation in study, growth and renewal. Indicate experiences by which you have endeavored to strengthen your ministry in these ways during the past 5 Years:

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* 13. If you check marked above that you have attended trainings, please list the date of attendance, organization/person that provided it and place it occurred.

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* 14. Are you willing to be a faithful minister serving within and supportive of the Christian Church (Disciples of Christ)?

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* 15. Have you reviewed and agree to adhere to the “Ministerial Code of Ethics”?

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* 16. Have you ever been charged with or convicted of a felony?

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* 17. Have you ever been charged with or convicted of any crime against persons?

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* 18. Is there any reason that you should not be entrusted with the care, guidance or supervision of children or youth?

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* 19. Are there any ways the Regional Commission on Ministry or the Regional Minister and staff can be of assistance to you at this phase in your ministry?

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* 20. This is a space for you to add any comments for further explanation or clarification on questions that you needed to expound on. 

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