Name *

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Church Name

First Name

Last Name

Church Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Pastor Name (If Applicable)

First Name

Last Name

Are you able to commit to a 12-week program with weekly sessions? *

Yes

No

Are you able to make an investment of $1,200? *

Yes

No

Statement of Commitment *

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a participant, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal from the cohort.

I agree