Application Form - International

URL

This field is for validation purposes and should be left unchanged.

Name(Required)

First Last

Email(Required)

Phone(Required)

Country(Required)

What country and city (or town/village) will your group be located?

City or town(Required)

Name of Current Church(Required)

Church Affiliation(Required)

Denomination/Non-denominational, etc.

Have you ever been arrested or convicted of criminal charges other than minor traffic violations?(Required)

Yes

No

Please describe the circumstances and results of the criminal charges(Required)

Have you ever been investigated for abuse of a person, fraud, or theft?(Required)

Yes

No

Please describe the circumstances and the results of the investigation.(Required)

Do you or have you had personal experience with chronic pain or illness?(Required)

Yes

No

What training or experience have you had that you believe will help you in leading a Broken and Mended group?(Required)

Why do you want to lead a Broken and Mended support group?(Required)

Where do you intend to recruit your first group members?(Required)

How did you hear about Broken & Mended?(Required)

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Application Form – International