Membership Application

Membership Application

Contact Information

Email Address: 

Daytime phone: 

Evening phone:

URL: 

Fax: (call first? yes no)

Mailing address: (Your mailing address will not be given to ANYONE.) 

City 

State/Prov 

Zip/Postal Code 

Country 

Coaching Information

Coaching full time part time

If part time, what is your full time profession? 

What was your profession/career prior to coaching? 

Are you presently enrolled in Coach Training? yes no

If yes: I am enrolled in (name of school) Coach Training Program

I graduated from (name of school) Coach Training Program date

I hold the following coaching designations/certifications: 
(please list the certification, the name of granting organization, and the date) 

If you do not have specific coach training, describe your understanding of professional coaching: 

Do you presently or plan to coach minors?YesNo

Christian Information

Complete the following sentences, according to your beliefs: 

a) I believe that Jesus Christ is:

b) My Christian life/experience is: 

Reference: (name and contact information of pastor, church leader, or person who knows you well as a Christian.)

Name: 

Position: 

Phone: or Email:

Were you invited to join CCN by a member?  If so, who?

What else would you like us to know? 

AGREEMENT

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