Assessment Couples Registration

Tell us about yourself

Name*

First Last

Email*

Enter Email Confirm Email

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Tell us about your spouse

Spouse Name*

First Last

Spouse Email*

Enter Email Confirm Email

Spouse Phone*

How long have you been married?*

Share a photo of you and your spouse or family

Do you have children? If yes would you tell us either their names / ages or just ages of children. Whatever you are comfortable sharing.*

Please indication which date you in which would like to participate*

Fun Facts about you & your spouse

Tell us about you and your spouse...*

What do you do for fun? A fun fact about each of you, things you like to do, etc. We like details so do be afraid to over share.

Church / Church Plant Information

Church/Network Name*

Please tell us the name of the church or church planting organization with whom you are associated.

Church/Network Location*

Church/Network website

Your Position within the church plant*

Does your spouse hold a position within the church plant?*

What position will your spouse hold?*

Tell us about your education and experience in church planting.

Education Information*

Please tell us about your education history; degrees held, schools graduated from, etc.

Have you attended seminary?*

Yes
No

Seminary Name, Location & Degree*

My church planting experience includes...*

List the Church information for the churches you have helped plant.

Church Name	Location	Size	Your Role

Tell us about the demographic profile for who you reached

urban, rural, impoverished, 25-35yr olds, etc... describe the majority you reached

Explain the culture of the churches you worked in.

(ex: "come-as-you-are," laid back, formal, diverse, multi-cultural, traditional, etc.)

Payment Options

Please choose your method of payment and enter any coupon codes below.

GLI Assessment Center Couples Registration*

Price: $1,295.00 Quantity:

Cost does not include travel and transportation to the event. The attendee is responsible for all travel.

PrePaid/Coupon Code

Total

$0.00

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Additional Comments

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Name

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