2019 Commissioned/Endorsed Member Renewal Form ANNUAL REPORT OF YOUR MINISTRY FOR THE LAST YEAR Please apply for renewal by one of the following 2 ways: 1. Send The Application Form By Mail: Download PDF 2. Fill Out The Application Form Below. First Name Last Name Birthdate Physical Address Street City State Zip Mailing Address Street City State Zip Preferred Phone: Home Cell Work Alternate Phone: Home Cell Work Email My ministry colleague is We last met on How often did you meet with your ministry colleague/peer? Please choose from these options for identification on your 2019 FCM membership card and certificate: Title Rev None Name (first, middle, last) One Academic Degree (optional) 1. Are you a member of a professional organization? No Yes 2. If Yes, please designate below the organization: AAPC:Student AAPC:Member AAPC:Pastoral Care Specialist AAPC:Certified Pastoral Counselor AAPC:Fellow AAPC:Diplomate ACPE:Student ACPE:SES ACPE:Candidate ACPE:Associate ACPE:Full APC:Member APC:Board Certified Chaplain APC:Provisional Board Chaplain APC:Board Certified Associate Chaplain APC:Provisional Board Certified Associate Chaplain CPSP:Diplomate Pastoral Psychotherapy CPSP:Diplomate Pastoral Supervisor CPSP:Pastoral Counselor CPSP:Associate Pastoral Counselor CPSP:Board Certified Chaplain CPSP:Board Certified Associate Chaplain Other Organization Designation Other Organization Designation 3. Did you achieve a change in membership status in your professional organization in 2017? No Yes 4. Did you have any significant changes or events in your family, work, or personal life? No Yes a. Please describe b. How can FCM can be helpful to you? 5. What have you done this year to care for yourself physically, mentally and/or spiritually? Your Main Ministry Additional ministries Do you belong to a community of faith? No Yes If "no" would you like to join or form one? No Yes Can you introduce them to FCM group membership? No Yes Describe your PARTICIPATION within the FCM community during the past year. The purpose of the bi-annual National Assembly is to build community, support ministry, and provide professional update. How many assemblies and regional gatherings, have you attended these past 3 years? I have updated my knowledge/skills in ministry this past year by (e.g., taking or teaching a course, attending seminars, reading books) To support FCM and its Mission I will: be an Area Representative; host an FCM gathering; write an article for the Newsletter; other; Other It is the position of FCM that each member of FCM holds primary responsibility for maintaining appropriate professional and personal boundaries in all ministerial relationships. Within the past year, have accusations been made about you,have you been convicted of a felony, or have you had any disciplinary action taken against you, or are any such actions pending by any licensing and/or certifying authority? Are there similar past actions which have not been declared to FCM? No Yes All members please read, sign and date the following: PLEASE READ, SIGN AND DATE THE FOLLOWING If you answered yes, please explain fully on an additional sheet of paper. I have read the Constitution/By Laws, Ethics Statement and Professional Practices Policy of the Federation of Christian Ministries and agree to abide by the conditions specified in these documents. http://www.federationofchristianministries.org/index.php/about-fcm Signature (Full Name) Date You must make your payments in order to complete the process. After you submit this form, go to our Online Payments page, where you can make your payments.