LAY FAMILY COUNSELING CERTIFICATION

Program

Church/Community Involvement

STUDENT INFORMATION

Name

Suffix

Gender

Title

Phone

Email

Home Address

CHURCH MEMBERSHIP

Are you a member of Greater New York Conference?

Yes No

If no, what is your home conference?

Name of Church

Name of Pastor

OFFICE USE ONLY-- Payment Information

Student Paid:

Church/Entity Paid:

Conference Paid: