* Name:

Title:

Gender:
Male   Female
Address:

City:

State:

Zip:

Telephone:
    (Work)
    (Home)
    (Cell)
* Email:

I am: (ordained, commissioned, lay, etc)

Congregation:

City/State:

Denomination:

Conference/Synod/District:

....................................................

Question 1:
Paid staff: Provide a short summary of your theological education and your most recent two ministry positions.
Lay volunteer: Describe your present role(s) in congregational leadership.

Question 2:
Describe what you hope to gain by participating in this program.

Question 3:
Faithfulness in attendance is vital for this program. All workshops will run from 5:45 p.m. on the first day to 3:00 p.m. on the third day (2009: April 26-28, August 21-23, November 15-17; 2010: April 18-20, August 20-22, November 12-14)

Do you anticipate difficulty attending any of the six sessions?
    Yes   No

If "yes," please explain:


Do you anticipate any difficulty in participating in a one-hour online seminar after each event?
    Yes   No

If "yes," please explain:

Question 4:
SPLaSh is for leaders in congregations that are ready and willing to grow in health and faithfulness; it is not appropriate for overly conflicted congregations. Describe how you view the role of conflict in your current congregation.

Question 5:
Paid staff: Does your congregation know about SPLaSh?
    Yes   No
Does your governing board support you?
    Yes   No
Lay volunteer: Is your senior pastor supportive of your participation in this series?
    Yes   No

Your application requires a reference from someone on your congregation's governing board. After submitting this form, you'll see further instructions about the reference procedure.