Application Form - USA - Broken & Mended

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Application fee:

Product Name

This form always has a $25 cost

Payment Method(Required)

American Express

MasterCard

Visa

Supported Credit Cards: American Express, MasterCard, Visa

Card Number Expiration Date Security Code Cardholder Name

Applicant Contact Information

Name(Required)

First Last

Email(Required)

Phone(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

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

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

Have you ever been terminated from any leadership roles you have held?(Required)

Yes

Please explain the details concerning the termination.(Required)

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

Will you be able to provide virtual access to your meeting for those who are unable to attend physically?(Required)

Yes

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

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

Personal Reference

Please provide the name and contact information of a personal reference. This may be your pastor, a mentor, a ministry leader in your church, a professional colleague, or other person in your life who can speak to your character and who supports your desire to lead this group.

Reference Name(Required)

First Last

Reference Email(Required)

Reference Phone(Required)

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

Confirmation(Required)

I agree to the privacy policy.

Confirmation(Required)

I affirm the Broken & Mended Statement of Faith

https://brokenandmended.org/statement-of-faith/

Confirmation(Required)

I agree to only use the Broken & Mended materials in accordance with their copyrights

Application Form – USA

Applicant Contact Information

Personal Reference

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