L-6(23)

Name Address City/State/ZIP Homephone Workphone E-mailaddress

1.DescribewhyyouareinterestedinbecomingaStephen Minister.

2.WhatspiritualgiftsorstrengthsdoyoubelieveGodhasgivenyouthatwouldhelpyouserveeffectively asaStephen Minister?

3.Inwhatwaysdoyouthinkyouwouldbenefitpersonallyfromyourtraining andserviceas aStephenMinister?

4.BasedonyourcurrentunderstandingofwhatitmeanstobeaStephenMinister,whatdoyouthinkwouldbedifficultorchallengingaspectsofthisroleforyou?

5.Howwouldpeoplewhoknowyoudescribethewayyourelatetoothers?

Copyright©2000byStephenMinistries,St.Louis.Allrightsreserved.Permissionto makecopiesofthisdocumentisgivenONLYtoenrolledStephenSeriescongregationsandONLYfor use within theenrolledcongregation.

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L-6(23) StephenMinister Application C:1/1/2000 R: 1/9/2007

6.Areyouwillingtocommittoservefaithfullyforaperiodofnolessthantwoyears?Thisincludes:

�theinitial50hoursoftraining;

�regularvisitstoyourcarereceiver(weeklyoramutuallyagreed-uponfrequency);and

�twice-monthlySmallGroupPeerSupervision.

DYes DNo

Whatchangeswouldyouneedtomakeinyourlifeinordertofulfillthiscommitment?

7.DescribebrieflyyourrelationshipwithJesusChrist.

8.Please providethreereferences who are not members of thiscongregation.

a.Name Address Relationship Phonenumber

b.Name Address Relationship Phonenumber

c.Name Address Relationship Phonenumber

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2Copyright©2000byStephenMinistries,St.Louis

9.Have you ever trained and served as a Stephen Minister or Stephen Leader at anothercongregation?

DYes DNo

Ifyes,pleaselistwhereandwhen.

Pleaseincludethenameandtelephonenumberofapastorand/orStephenLeadertherewhomwecancontact.

NameTelephoneNumber()

10.Have you ever receivedtreatment forany emotionalor psychiatricproblems?

DYes DNo

Ifyes,someonefromtheStephenLeaderTeamwillspeakwithyouaboutthissothattheteammaybetterunderstanditssignificanceinyourlifeandministry.

[Note:Agreatmanycaregivershavebeenmadestrongerintheircaregivingministrythroughthecaretheythemselveshavereceived,includingcarefrommentalhealthprofessionals.YourStephenLeaderTeamaffirmstheworkofmentalhealthprofessionals,whohavehelpedmanyindividualstoexperiencegrowthandhealing.MembersoftheStephenLeaderTeamrequestthisinformationbecausetheywanttobeasfullyinformedaspossibleabouttheirStephenMinisters.]

11.Haveyoueverbeenchargedwithacrime?

DYes DNo

Ifyes,explainindetail,usingadditionalpaperasneeded.SomeonefromtheStephenLeaderTeamwillspeakwithyouaboutthissothattheteammaybetterunderstanditssignificanceinyourlifeandministry.

Pleasereadandsignbelow.

TheinformationIhaveprovidedinthisapplicationistrueandcompletetothebestofmyknowledge.IagreetoparticipateinStephenMinistrytrainingandinSmallGroupPeerSupervisionandtofunctionwithintheboundariesofStephenMinistryasadoptedbymycongregation/organization.Igivepermissionforthecongregation/organization,ifitdeemsnecessary,tocallmyreferences, secure a policebackgroundcheckonme,andconsultwiththetreatingphysician(s)orothermentalhealthprofessionalsregardingthenatureofanytreatmentIhavereceivedforemotionalorpsychiatricproblems.

SignatureDate

Thank youforcompleting this application.

L-6StephenMinisterApplication3