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First Name:
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Middle Initial:
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Last Name:
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Address:
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Address Cont:
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City
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State
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Zip Code
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Home Phone:
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Work Phone:
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Cell Phone:
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Email Address:
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Are you an Ordained Minister?
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Yes
No
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Date of Ordination:
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What is your clergy status:
(i.e. license, certified deacon etc.)
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In what church or denomination?
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What is your current professional Ministry (i.e. pastor, chaplain)?
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Full time or part time?
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Full Time
Part Time
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If a pastor, church or churches you currently pastor.
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Please list the theological school(s) you have attended, include dates of graduation(s) and Degree(s) you have earned in your ministerial training:
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Are you a minister in good standing?
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Yes
No
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If yes, what is your home church?
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Where and when did you make your Emmaus Walk, or 4th day weekend (please specify)?
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Have you attend and Emmaus/Chrysalis clergy training conducted by the Upper Room staff or a Clergy Regional Representative?
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Yes
No
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If yes, date & community:
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Previous team experience as a layperson (Please list by Community name followed by Walk/Flight/Journey number, jobs held, talks given:
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Previous Team experience as a clergyperson (Please list by community name followed by Walk/Flight/Journey number:
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For the Emmaus and Chrysalis Clergy talks below, please check all that you have given:
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Prevenient Grace
Justifying Grace
Means of Grace
Obstacles to Grace
Sanctifying Grace
God Designed You
God Love You
God's Gift to You
God Sustains You
God Empowers You
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Have you ever served as the Weekend/Head Spiritual Director on a Walk/Flight/Journey? If yes, give community name and Walk/Flight/Journey number.
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Please enter today's date and your initials to verify completion.
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