This worksheet is provided for draft purposes only. The actual form must be entered and submitted in Arena at least 10 days prior to the scheduled date of your church conference.

Part 1)Personal Data

Name (Mrs. __ Ms. __ Mr. __) ______

Address ______

City/State/Zip ______

Telephone (H) ______(C)______

E-mail ______

Name of District ______

Name of Church ______

Church Address ______

City/State/Zip ______

Church Telephone ______

(Part 2)CURRENT STATUS-- Note: You will need to scan and upload your certificates along with the information you provide in this section when you enter the final report in Arena.

  1. Module 1 Complete Date?______(certificate required)
  2. Module 2 Complete Date?______(certificate required)
  3. Module 3Complete Date?______(certificate required)
  4. Module 4Complete Date?______(certificate required)
  5. Date of your original certification by DCOM or CCLSM? ______(certificate required)
  6. Date of your last Re-certification Course?______

Title of your last Re-certification Course?______(certificate required)

  1. What is the date of your current certification by DCOM or CCLSM?______

(Part 3) MINISTRIES

During the past year, I participated inCARING MINISTRIESas follows:

__ served as a volunteer in a care-giving institution

__ provided one-on-one caring

__ at a hospital, nursing home, or to a shut-in

__ in membership/evangelism visitation

__ served in caring/outreach projects (food pantry, prison ministry, etc.)

__ other CARING activities(Please list) ______

During the past year, I participated inLEADING MINISTRIES as follows:

__ served as member of committee, board, commission, council, task force, etc.

__ as a volunteer at a community agency

__ at my local church

__ beyond my local church

__on my District __ Conference __Jurisdiction __General Church level

__other LEADING activities(Please list) ______

During the past year, I participated in COMMUNICATING MINISTRIES as follows:

__ sharedthe message in ______worship services

__ served as worship leader in ______services

__ delivered ______devotional messages

__ taught ______classes

__ shared my faith story to ______

__ other SPEAKING activities(Please list) ______

During the past year, I participated in additional opportunities for ministry as follows:

______

______

______

(Part 4) PERSONAL AND SPIRITUAL GROWTH

In what activities, have you engaged in/or what books have you read or used during the past year to help you develop your devotional life; improve yourunderstanding of the Bible; improve your understanding of The United Methodist Church; and to improve your skills in caring, leading, communicating and speaking?

______

______

(Part 5)FEEDBACK

Do you feel called to be in service in any area of ministry, either in the church or outside the church, in which you are not currently involved? __ yes __ no If yes, please list those areas below:______

Other comments about your year of ministry you would like to add:

______

Signatures;

By my signature, I/we affirm that the individual making this report is eligible to continue in Lay Servant Ministries:

Certified Lay Servant/ Certified Lay Speaker/ Certified LayMinister:

______DATE______

Pastor: ______DATE______

Chair of Church Council:______DATE______

Presiding Elder?????