Pastoral Care School - Registration

Registration Form

Pastoral Care School (PCS) East - April 30 - May 4, 2012

Holiday Inn Columbus - Worthington
OH 43085, USA

*Required fields

Your Information:
*First Name:
*Last Name:
*Gender:	Male Female
*Marital Status:
*Age Group:
*Email Address:
*Mailing Address:
*City:
*State/Province:
*Zip Code:
*Phone:
*Occupation:
*Church you attend:
*Attended a PCS before?	Yes No
If yes, date attended:	Apr/02 Oct/02 Jan/03 Nov/03 Mar/04 Nov/04 Apr/05 Dec/05 Apr/06 Dec/06 Apr/07 Dec/07 Apr/08 Dec/08 Apr/09 Dec/09 Apr/10 Dec/10 Dec/11
*Why do you wish to attend this PCS?
Do you involve in healing prayer ministry? Please describe.

Special Request:
"List any significant medical conditions and prescribed medications if applicable:"

Reference Person:
*Name:
Phone:
Email:
PCS Alumni?	Yes No

*Does your spouse enroll this PCS with you?	Yes No

Your Spouse's First Name:
Your Spouse's Last Name:
Your Spouse's Email Address:
Your Spouse's Occupation:
Church your spouse attends:
Attended PCS before?	Yes No
If yes, date attended:	Apr/02 Oct/02 Jan/03 Nov/03 Mar/04 Nov/04 Apr/05 Dec/05 Apr/06 Dec/06 Apr/07 Dec/07 Apr/08 Dec/08 Apr/09 Dec/09 Apr/10 Dec/10 Dec/11
Why does your spouse wish to attend this PCS?
Does your spouse involve in healing prayer ministry? Please describe.

Disclaimer: San Jose Christian Alliance Church and Pastoral Care School, hereby disclaim any and all responsibility or liability for any adverse or damaging effects which may be asserted or claimed to have arisen, either directly or indirectly, as a result of participation in this School. "I understand that my accepted application is non-refundable nor transferable to another applicant.
I/We agreed, hereby release SJCAC, PCS and associates from any such responsibility or liability. I/We Understand that I/We required to reside full-time in the PCS campsite and to attend ALL sessions "Acceptance is pending upon the review of this application.? Please do NOT make any travel arrangement UNTIL you receive confirmation from PCS registrar."

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