10-Core Training Registration

Core Chaplaincy Training Registration

You may start this registration and complete it at a later time by clicking "Save & Resume Later" at the very bottom of the form.

Contact/Personal Information

Name*

First Name

Last Name

Preferred Name?

Date of Birth (mm/dd/yyyy)*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Cell Phone Number

Home Phone Number

Email*

How did you learn about our training?

Tell Us About Your Connection to the Local Church

Church Name/Location*

Format: Bible Baptist Church/Raleigh, NC

Denomination*

Are you serving as a Chaplain now?*

Yes No

Where are you currently serving (include City/State) and how long have you served there (In years)?*

Have you ever served as a Chaplain perviously?*

Yes No

Where did you serve (include City/State) and how long did you serve there (In years)?*

List other activities and groups that you are involved with (i.e. Civic Clubs, Professional Associations, etc...)

When you click submit below, you will be redirected to pay $120 for the Core Training Courses

Payment will be made...*

Under My Name Under Another Name

Name payment will be made under...

Cost

# of Reg