Registration

[Company Logo Image] Registration

Urban Poor Discipling Movements

Class/Consultation Registration

Registration Details:

Name: Pr/Mrs/Mr/Miss First names: _____________________Last name: ______________________________

Date of Birth: day________month _________year___________

Single/married/separated/divorced/widowed (Please circle the correct one)

How many children (ages)__________________

Address____________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________
City____________State_____________Postcode_______Country_________

Postal Address if different to the above: _________________________________________________

__________________________________________________________________________

Telephone No: ________________________ Email address: __________________

Educational Qualifications:

Primary School - 5yrs to 12yrs: Yes/No (circle one)

Secondary School – 13 to16yrs+: Yes/No (circle one)

Graduate from Secondary School? Yes/No (circle one)

Do you hold any tertiary qualifications (University, Bible School etc)? Yes/No (circle one)

Qualification and the year attained.

__________________________________________________________________________

Community Service details:

Have you served in any community service roles whether paid or voluntary?

Please state the details, names of organisation, roles, dates of service etc.

__________________________________________________________________________

Name of organisation/church you work for or are associated with:

__________________________________________________________________________

Postal address of that organisation/church_______________________________________________

__________________________________________________________________________

Name of the leader you are accountable to: ______________________

Do you have a spiritual mentor/supervisor? Yes/ No

If you answer was Yes, please provide details of the mentor/supervisor;

Name:__________________________________________________ PostalAddress________________________________________________________________

__________________________________________________________________________

Tel. No. __________________Email Address:___________________

Christian history:

When did you become a Christian? Year________

When were you baptised? Year_______

When did you become a Church member? Year_______

How long have you been a Church leader? Years_______

What experience have you had as an urban poor church planter?

__________________________________________________________________________

What experience have you had as an urban poor church worker?

__________________________________________________________________________

What Churches or organisations have you served with during this time? Please give a brief history of you service with these the latest of these churches/organisations?

__________________________________________________________________________

In what role did you serve in each of these churches/organisations?

__________________________________________________________________________

Character References:

Please provide the names of two Christian leaders who know you well and could provide a character reference about you?

Name:_______________________________________ Title:_______________

Postal address: _______________________________________________________

Name:__________________________________________________ Title:_______________

Postal address: __________________________________________________________________________

__________________________________________________________________________

Resources:

Do you own your own computer? Yes/No

Make of the Computer?______________Model?____________________________

Operating System?_Windows 98, 2000, XP, _______(Circle one)

Do you have Microsoft power point software? Yes/No

Do your own your own TV? Yes/No

Do you own a DVD player? Yes/No

Is the above equipment available for use for 2-5 hours per week for the grass roots training program?

Fill in and give to the training coordinator on the first day of training.

© Viv Grigg & Urban Leadership Foundationand other materials © by various contributors & Urban Leadership Foundation, for The Encarnacao Training Commission. Last modified: July 2010