VIRTUAL COUNSELOR REGISTRATION FORM

Please set aside enough time to complete this application in one sitting

Gender
Are you 18 years or older?
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Emergency Contact Infomration

Personal Information (Volunteer Disclosure)

Have You Ever Been Convicted of any crime relating in any manner to children and/or your conduct with them?
Are you now or have you ever been subject to any court order involving sexual or physical abuse of a minor, including, but not limited to a domestic order or protection?
Have you ever been adjudged liable for civil penalties or damages involving sexual or physical abuse of children?

Personal Testimony

Please write out your testimony, roughly one page in length, explaining when and how you became a Christian. Also, Include any important decisions, experiences or Bible verse that have impacted your Christian life.

I hereby affirm and acknowledge that the answers given by me to the foregoing questions are complete and true to the best of my knowledge and belief.
I have also read and affirm the Statement of Belief and Code of Conduct.

Thanks for submitting!