State, Province or Region:
Home phone number:
Work phone number:
Community to which you belong to (if applicable):
We want to get better acquainted with you, our new member, so that FCM can serve your needs and call upon your talents to help others. Optionally, a small photo of you is appreciated. If you prefer to use your own format, please feel free to do so, as long as the following information is included. Optionally, a small photo of you is appreciated, email a JPEG photo to:
What led you to join FCM?
Describe your present ministry:
Describe life experiences and education pertaining to this ministry:
What educational degrees and professional licenses do you hold (if applicable)?
FCM ministers are committed to providing a safe environment for those to whom they minister. Therefore, FCM does not accept for membership persons convicted of physical, sexual or other types of violence toward another person.
Applicants are subject to background checks, including liens, and waive the right to privacy regarding these investigations. By completing this membership application, you agree to the terms of membership.
MEMBERSHIP IN FCM IS BASED ON THE FOLLOWING REPRESENTATIONS
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. It is also assumed that when a person joins FCM, and especially when certified, that he/she has attained emotional and sexual maturity thereby allowing the FCM member to minister comfortably with persons of any age or gender who may come for assistance. Therefore, membership in FCM is based on the following representations, and the signature of the member will indicate understanding of, and agreement with, these standards. Please answer Yes or No to the following questions.
1. Have you ever been convicted of or charged with a crime in any state or country, the disposition of which was other than acquittal or dismissal? (A juvenile finding of responsibility or involvement, or similar determination, shall be explained as if it were an adult conviction. Any probation before verdict or similar disposition program shall be fully documented as well.)
2. Has any certifying or licensing board or professional ethics body in any state or country ever required you to surrender your license or certificate or found you guilty of a violation of ethics codes, professional misconduct, unprofessional conduct, incompetence or negligence (including alternative dispute resolution cases)?
3. Are there any complaints, charges or investigations by any certifying or licensing board or professional ethics body pending against you in any state or country for violation of ethics codes, professional misconduct, unprofessional conduct, incompetence or negligence (including alternative dispute resolution cases)?
4. Have you ever had any insurance company or Lloyd's decline, cancel, refuse to renew or accept only on special terms any professional liability insurance?
5. Has any professional liability claim or suit ever been made against you (including alternative dispute resolution cases)? Yes:
6. Are there any circumstances of which you are aware that may result in any professional liability claim or suit being made against you (including alternative dispute resolution cases)?
7. Have you ever been accused of sexual misconduct with any of your current or former clients including but not limited to spiritual direction clients, mental health clients, or any other persons with whom you have had a professional, pastoral or other similar relationship of confidence and trust, or with any current or former clients spouse or with any person in a close personal relationship to the client or former client (for example, a guardian, blood relative or the client or spouse of any person sharing the client's domicile)?
For purposes of this inquiry, ‚¢¢‚¬Å¡‚¬ƒ€¦¢‚¬Å“client‚¬‚ shall include, but is not limited to, persons with whom you have or have had, at any time, any professional, penitential or any other pastoral relationship. Yes:
The Federation of Christian Ministries does not assume nor accept responsibility for the actions and practices nor the results therefrom of any of its ministers, present or past. The applicant/renewal member hereby represents that to the best of his/her knowledge the statements set forth herein are true. If the information supplied herein changes between the date of application and the time when the FCM membership/renewal is
issued, or subsequently at any time the applicant/renewal member remains a member of FCM, the applicant/renewal member shall immediately notify FCM.
WAIVER AND RELEASE FORM
I know that membership in FCM is based on the above representations, and my signature below indicates the understanding of, and the agreement with, these standards. By submitting this form, I consent to the exchange of information and documents among any and all persons, institutions, individuals, licensing agencies, and federal and state governmental bodies with whom I have been associated that are material to evaluating and monitoring my professional practices, qualifications, competence, morality and ethics. I also understand that the Federation of Christian Ministries will rely upon the information given in this form to admit me to membership in the Federation. I also agree to inform the Federation of any changes or modifications to the information provided herein, so that at all times the Federation will have accurate and current information.
AGREE TO THE ABOVE WAIVER AND RELEASE FORM:
I agree I do not agree
This application/renewal does not bind either FCM or the applicant/renewal member. However, it is agreed that this form shall be an integral part of the contract should membership be issued and will be attached to and made part of the application/renewal criteria. This application/renewal must be signed, dated, fully completed and accompanied by the required fee.
You must pay a $50 application fee in order to complete the application process. After you submit this form, you can visit our Online Payments page, where you can make your payment.