Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Work Phone

(###)

###

####

Cell Phone *

(###)

###

####

Do you consider your ministerial status as *

Active

Retired

If Retired, do you consider yourself *

(Note: "Active," in this usage, means that you are open, if called, to serving in a ministerial capacity.)

Active

Inactive

6 a.) Healthy Boundaries? *

Yes

No

I Don't Know

Retired, Not Applicable

If Yes, please provide date/year__________

6 b.) Anti-Racism/Pro-Reconciliation? *

Yes

No

I Don't Know

Retired, Not Applicable

If Yes, please provide date/year__________

8.) Do you have professional or pastoral needs that you would like to discuss with the Regional Minister or with the Committee on the Ministry? *

Yes

No

I believe that I currently meet the requirements for the continuation of ministerial standing as they are stated in the document, "Theological Foundations and Policies and Criteria for the Ordering of Ministry of the Christian Church (Disciples of Christ)," section II.F.2.b., and I request continuation of ministerial standing for the next year. *

Yes, I agree with this statement

No, I do not agree with this statement

E-signature *

First Name

Last Name

Today's Date *

MM

DD

YYYY