Certificate 2016 LNP App Contact Information First Name Middle Name Last Name Maiden/Former Name Preferred Name Email Confirm Email Phone Address City State/Province Zip/Postal Code CountryPlease select... UNITED STATES CANADA AFGHANISTAN ÅLAND ISLANDS ALBANIA ALGERIA AMERICAN SAMOA ANDORRA ANGOLA ANGUILLA ANTARCTICA ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA, PLURINATIONAL STATE OF BONAIRE, SAINT EUSTATIUS AND SABA BOSNIA AND HERZEGOVINA BOTSWANA BOUVET ISLAND BRAZIL BRITISH INDIAN OCEAN TERRITORY BRUNEI DARUSSALAM BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CAPE VERDE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA CHRISTMAS ISLAND COCOS (KEELING) ISLANDS COLOMBIA COMOROS CONGO COOK ISLANDS COSTA RICA CÔTE D'IVOIRE CROATIA CUBA CURAÇAO CYPRUS CZECH REPUBLIC DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FALKLAND ISLANDS (MALVINAS) FAROE ISLANDS FIJI FINLAND FRANCE FRENCH GUIANA FRENCH POLYNESIA FRENCH SOUTHERN TERRITORIES GABON GAMBIA GEORGIA GERMANY GHANA GIBRALTAR GREECE GREENLAND GRENADA GUADELOUPE GUAM GUATEMALA GUERNSEY GUINEA GUINEA-BISSAU GUYANA HAITI HOLY SEE (VATICAN CITY STATE) HONDURAS HONG KONG HUNGARY ICELAND INDIA INDONESIA IRAN, ISLAMIC REPUBLIC OF IRAQ IRELAND ISLE OF MAN ISRAEL ITALY JAMAICA JAPAN JERSEY JORDAN KAZAKHSTAN KENYA KIRIBATI KOREA, REPUBLIC OF KUWAIT KYRGYZSTAN LATVIA LEBANON LESOTHO LIBERIA LIBYAN ARAB JAMAHIRIYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAO MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MAYOTTE MEXICO MICRONESIA, FEDERATED STATES OF MOLDOVA, REPUBLIC OF MONACO MONGOLIA MONTENEGRO MONTSERRAT MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NAURU NEPAL NETHERLANDS NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NIUE NORFOLK ISLAND NORTHERN MARIANA ISLANDS NORWAY OMAN PAKISTAN PALAU PALESTINIAN TERRITORY, OCCUPIED PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES PITCAIRN POLAND PORTUGAL PUERTO RICO QATAR RÉUNION ROMANIA RUSSIAN FEDERATION RWANDA SAINT BARTHÉLEMY SAINT KITTS AND NEVIS SAINT LUCIA SAINT MARTIN (FRENCH PART) SAINT PIERRE AND MIQUELON SAINT VINCENT AND THE GRENADINES SAMOA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SENEGAL SERBIA SEYCHELLES SIERRA LEONE SINGAPORE SINT MAARTEN (DUTCH PART) SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SPAIN SRI LANKA SUDAN SURINAME SVALBARD AND JAN MAYEN SWAZILAND SWEDEN SWITZERLAND SYRIAN ARAB REPUBLIC TAIWAN, PROVINCE OF CHINA TAJIKISTAN TANZANIA, UNITED REPUBLIC OF THAILAND TIMOR-LESTE TOGO TOKELAU TONGA TRINIDAD AND TOBAGO TUNISIA TURKEY TURKMENISTAN TURKS AND CAICOS ISLANDS TUVALU UGANDA UKRAINE UNITED ARAB EMIRATES UNITED KINGDOM URUGUAY UZBEKISTAN VANUATU VENEZUELA VIET NAM VIRGIN ISLANDS, BRITISH VIRGIN ISLANDS, U.S. WALLIS AND FUTUNA WESTERN SAHARA YEMEN ZAMBIA ZIMBABWE Please upload a photo of yourself. Please limit file size to under 2MBs. Date of Birth Please format as (10/22/1970) GenderPlease select... Female Male Which of the following best describes your relational status?Please select... Single Married/Partnered Divorced Widowed Please describe your ethnic heritage: Additional Information How and when did you first hear about the Leadership in the New Parish Certificate at The Seattle School? Who or what influenced you to apply?The Seattle School FacultyTeacher or ProfessorThe Seattle School PublicationVisit to CampusCounselor or TherapistPastor or MinisterAdmissions RepresentativeThe Seattle School AlumnusCurrent Seattle School StudentConference or WorkshopThe Seattle School websiteFamily or FriendParish CollectiveOther Other Influence Have you participated in offerings through The Seattle School, The Forum, Parish Collective, or The Allender Center? Select all that apply.Inhabit ConferenceParish Collective GatheringNew Parish Book Tour EventStanley Grenz Lecture SeriesPastor's Breakfast at The Seattle SchoolLecture or Event with The Forum at The Seattle School The Seattle School Degree ProgramAllender Center Certificate ProgramStory WorkshopOther Other participation. Highest level of education completedPlease select... GED High School Bachelor Master Doctoral School(s) attended Name of school Degree pursued Start date (estimate) Please format as (05/10/1970) End date (estimate) Please format as (09/10/1972) Did you graduate?Yes Which of the following best describes your employment status?Please select... Student Part-time employment Full-time employment Not currently working or attending school Current Occupation: What is your denominational affiliation? (if applicable)Please select... NonDenominational Advent Christian Church African Methodist Episcopal African Methodist Episcopal Zion American Baptist Churches in the USA Anglican Church of Canada Assemblies of God Associated Gospel Churches (of Canada) Associate Reformed Presbyterian Church Baptist Convention of Ontario & Quebec Baptist General Conference Baptist Missionary Association of Americ Baptist-Other Baptist Union of Western Canada Brethren Church (Ashland, OH) Brethren in Christ Church Christian and Missionary Alliance Christian Brethren (Plymouth Brethren) Christian Church (Disciples of Christ) Christian Churches & Churches of Christ Christian Methodist Episcopal Christian Reformed Church Churches of Christ Churches of God, General Conference Church of God Church of God (Anderson, IN) Church of God in Christ Church of the Brethren Church of the Nazarene Conf. of Congregational Christian Church Conservative Baptist Assoc. of America Convention of Atlantic Baptist Churches Cumberland Presbyterian Church Episcopal Church, The Evangelical Church in Canada Evangelical Congregational Church Evangelical Covenant Church Evangelical Formosan Church Evangelical Free Church of America Evangelical Lutheran Church in Canada Evangelical Luthern Church in America Evangelical Presbyterian Church Fellow. of Evan. Baptist Church-Canada Foursquare Gospel Church Friends, Religious Society of General Assoc. of Regular Baptist Church General Baptist State Convention, NC Greek Orthodox Archdiocese in N/S Amer Independent Baptist Independent Methodist Jewish Lutheran Church - Canada Lutheran Church - Missouri Synod Lutheran - Other Mennonite, Other Mennonite Brethren Church in North Amer Mennonite Church, Canada Mennonite Church, USA Missionary Church in Canada Moravian Church in America Muslim National Baptist Convention New Jerusalem, General Church of North American Baptist Conference Orthodox, Other Orthodox Church in America Orthodox Presbyterian PCUSA Pentecostal Assemblies of Canada Presbyterian Church in America Presbyterian Church in Canada Progressive National Baptist Convention Protestant Reformed Church in America Reformed Church in Canada Reformed Episcopal Church Reformed Presbyterian Roman Catholic Salvation Army Seventh-day Adventist Seventh Day Baptist General Conference Southern Baptist Convention Swedenborgian Church, General Convention Union d'Eglises Baptistes Francaises-Can Unitarian Universalist United Church of Canada United Church of Christ United Methodist Church Wesleyan Church Wisconsin Evangelical Lutheran Synod None of these fit Denomination Other: Please list any dietary restrictions?: Organization What is the name of your parish/church/organization? This is my employer Role/Title Website How long have you been involved? In 3-4 sentences, provide some context about your neighborhood. Briefly describe your engagement in your neighborhood. Provide an example of a regular practice that roots you in your neighborhood. What do you desire/hope for your neighborhood? Briefly describe why you are drawn to the Leadership in the New Parish certificate and how you imagine the mission and ethos of this program will impact you and the presence you bring to your neighborhood. Recommendations & Compliance Please provide two references. We reserve the right to contact the references you provide to inquire about your character and readiness for the program. Reference 1 First Name Last Name Email Relationship Length of Relationship Reference 2 First Name Last Name Email Relationship Length of Relationsip Compliance Have you ever been suspended or expelled from an academic institution?YesNo Please provide a brief description of the circumstance(s). Do you have charges pending against you, entered a plea for, or been convicted for a crime other than a minor traffic violation?YesNo Please provide a brief description of the charges and/or crime. Have you ever required psychiatric or psychological treatment?YesNo Please provide a brief description of your treatment. The intent behind this question is to gather information about significant psychiatric or psychological treatment (e.g. recent experience or memory of intense trauma, onset of PTSD, hospitalization, suicide attempts, in-patient rehab). As a community we encourage and honor personal therapeutic work and do not discriminate against individuals who have sought help. If your answer to this question is "yes", we'd like to gain a greater understanding of where you are at in your own process in order to decide together whether or not this program would be safe and honoring for you at this time. Payment Information The cost of the Leadership in the New Parish certificate is $3950. Travel, lodging, and other expenses are not included in the cost of the program. We accept Americorp and other funding from outside sources. Tuition is not eligible for a charitable tax deduction. ScholarshipsA limited amount of scholarship funding is available for those demonstrating financial need. If you need financial support to make this training more accessible, please check the box below and describe your circumstances. Requests made before June 1, 2016 will be consider when your application is reviewed. Please be aware that scholarships range from $250-$1000. You will still be responsible for the majority of the cost of the certificate program. It is possible to find other avenues to help assist with the financial responsibility such as partnering with organizations, networks, or individuals you may be connected with. I'd like to apply for financial support Scholarship Request Briefly describe your financial circumstances and how a scholarship (ranging from $500-1000) would make the Leadership in the New Parish certificate program more accessible to you and your organization. Briefly describe additional resources for funding that you have access to (e.g. denominational funding, continuing education stipends, etc) Amount requestedPlease select... 250 500 750 1,000 I submit that all the information contained in my application is complete and correct. I understand that any falsification of information is grounds for expulsion. Accept Application Fee Fee: promo code apply code Name on card Cardholder Name different than above First Name Last Name Credit Card # Security Code Month Please select... 01 02 03 04 05 06 07 08 09 10 11 12 Year Please select... 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 Need assistance with this form?