In-Care Request Form

Name Details

Please use your complete *legal* name. If you do not have a middle name, please indicate NA.

First Name *

Middle Name *

Last Name *

Nickname or Common Name

Example: Robert = Bob or Rob

Preferred Pronouns *

He/His
She/Her
They/Them
Prefer not to answer.

Spouse or Partner's Name

Mailing Address

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone Numbers

Home Phone Number

Mobile Phone Number

Work Phone Number

Which of these phone numbers is your primary contact location? *

Home
Mobile
Work

You must have at least one phone number where you can be reached.

Email Address

Primary Email Address *

The email address you would like the Northern Lights Regional Office to use for *all* email from the Region.

Regional Email Opt-In

Yes, add my email address!
No thanks, I don't need to be included in Regional news.
I already receive them.

If you do not already receive email from the Region's MailChimp distribution service, would you like your primary email address to be added on your behalf?

Vital Statistics

Date of Birth *

Ethnicity *

Reason for Application

Are you... *

Seeking Ordination
Seeking Commissioning

Previous In-Care Experience

1. Have you ever been in-process or under-care with another region or denomination? *

Yes
No

1b. If yes, please explain when, where and reason for termination of process.

1c. Name and contact information for person in authority of your process in other region or denomination.

2. I authorize the NLR Commission on Ministry to contact the above individual to confirm the information listed on this form. *

Yes
No
Not Applicable

2b. If you selected "No," please explain why you are unable to authorize the NLR Commission on Ministry to contact the above individual.

Post-High School Education

1. Institution name, dates attended, degree achieved.

2. Institution name, dates attended, degree achieved.

3. Institution name, dates attended, degree achieved.

4. Institution name, dates attended, degree achieved.

Previous Employment

Please list your last three employers and your position beginning with the most recent.

Employer 1 | Most Recent

Employer 1: Start Date

Employer 1: End Date

Use today's date if you're still currently in this position.

Employer 1: Company Name

Employer 1: Address: Number/Street, City, State, Zip

Employer 1: Your Position/Title

Employer 2

Employer 2: Start Date

Employer 2: End Date

Use today's date if you're still currently in this position.

Employer 2: Employer/Company Name

Employer 2: Address: Number/Street, City, State, Zip

Employer 2: Position/Title

Employer 3

Employer 3: Start Date

Employer 3: End Date

Use today's date if you're still currently in this position.

Employer 3: Employer/Company Name

Employer 3: Address: Number/Street, City, State, Zip

Employer 3: Position/Title

Disclosure Statement

1. Have you ever been the subject of an official disciplinary review for misconduct conducted by a church body, professional association or other employer that resulted in censure, suspension of standing/employment or termination of standing/employment? *

Yes
No

If Yes, please explain:

2. Are any official disciplinary reviews pending against you at this time? *

Yes
No

If Yes, please explain:

3. Have you ever resigned or been asked to resign from employment, had paid or volunteer ministerial or secular employment terminated, had legal or ecclesiastical action taken due to any of the following (select all that apply):

4. Is there other information regarding this disclosure, or that may appear in a criminal background check or on a reference form, or might be discovered through the due diligence of the Commission on Ministry about which you would like to make a statement?

Release for Criminal Background Check

BACKGROUND CHECK AUTHORIZATION

By completing and submitting this form, "I certify that the above is true and accurate and that in my judgment there are no other facts or circumstances involving me or my background related to my being entrusted with the responsibilities of ministry in the Christian Church (Disciples of Christ). Further, I understand and an initial background check will be requested by the Northern Lights Region, at no cost to me, and that an additional background check will be performed, at my expense, before final approval for ordination, commissioning, or standing is given through the Office of Search and Call, a ministry of Disciples Home Missions and the Christian Church Disciples of Christ." (Current cost of later background check is $160.)

The Christian Church (Disciples of Christ) in the Northern Lights Region conducts initial background checks through the Praesidium company. When you submit this application, your contact information will be used to have an electronic background check authorization form sent to you by Praesidium. Please watch for that email within 24-48 hours of submitting this form. If you do not receive the email, please contact the office of the Northern Lights Region.

Signature

By pressing the "Submit" button, you acknowledge that you are accountable for the information submitted and that the answers to the questions above will be used, in part, to determine your qualification to participate in In-Care program of the Christian Church (Disciples of Christ) in the Northern Lights Region.