Start Your Own Group

Connecting Group Facilitator/Host Application

First Name	:
Last Name	:
Date of Application	:	1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Email	:
Date of Birth (MM/DD/YYYY)	:
Home Phone	:
Cell Phone	:
Work Phone	:
Address	:
City	:
State	:
Zip	:
Do you work outside the home?	:	yes no
If you answered yes, what is your occupation?	:
Are you a student?	:	yes no
If you answered yes, what college and degree option?	:
Marital/Parental Status	:	single married separated divorced widowed parent
If you checked that you are single, are you committed to the Biblical principles of sexual abstinence and non-cohabitation until marriage?	:	yes no Not Applicable I’d like to discuss this commitment with a pastor
If you checked that you are married or separated, what is your spouse's name?	:
If you checked that you are a parent, do your children currently live at home?	:	yes no
What are your children's ages?	:
Have you personally accepted Jesus Christ as your Lord and Savior?	:	yes no
Are you committed to having the character of Jesus live through you?	:	yes no
Tell us about your spiritual journey with Christ to date	:
Do you regularly attend weekly services?	:	yes no
If you answered yes, since when?	:
List the name of any other church or churches you have attended regularly during the past five years	:
Have you served at New Heights in the past?	:	yes no
If yes, since when?	:
List all current and previous church volunteering, type of work performed	:
I have chosen to pursue facilitating a Connecting Group at New Heights because…	:
Have you completed the New Heights Newcomers’ Class?	:	yes no
New Heights Church Attendee Reference #1: (Please choose one non-family member) First & Last Name:	:
Reference #1 Nature of association	:
Reference #1 Occupation	:
Reference #1 Length of time known	:
Reference #1 Address	:
Reference #1 City, State, Zip	:
Reference #1 Contact Number	:
Social Friend or Neighbor Reference #2: (Please choose one non-family member) First & Last Name:	:
Reference #2 Nature of association	:
Reference #2 Occupation	:
Reference #2 Length of time known	:
Reference #2 Address	:
Reference #2 City, State, Zip	:
Reference #2 Contact Number	:
Type of Connecting Group you want to start	:	Home Education Recreation Recovery Other
If you answered other, what kind of group would you like to start?	:
A brief, four words or less, accurate description of your group	:
Meeting Day	:
Meeting Time	:
Meeting Location	:
Will your group accommodate children and/or make provisions for childcare?	:	yes no
Fees or requirements associated with the group (e.g., $10 for study guide)	:
Please check 1 or 2 affinities your group could be listed under	:	College Age 18+ Singles 30+ Singles Young Couples Young Families Parents of Teens and Empty Nesters Multi-Generation: Children Welcome (open to all ages & stages: singles to young families to empty nesters) Multi-Generation: No Children (open to all ages & stages: singles to young families to empty nesters) Women’s Men’s Recreational Interest (e.g., hiking, motorcycling, book club, movie club, fine arts, arts & crafts) Educational Recovery
Signature: By checking this box, I certify that I am the person listed on this form and that I agree with the following statements:	:

The information contained in this application is correct to the best of my knowledge. I authorize any references or churches listed in this application to give you any information (including options) that they have regarding my character and fitness for work with connecting groups. I authorize the release of the information contained in this application to any ministry evaluation of this application by New Heights Church. I hereby release any individual, church, parachurch organization, charity, employer, reference or any other person or organization, including record custodians, both collectively and individually, from any and all liability for damages of whatever kind of nature which may at any time result to me, my heirs, or family on account of compliance of any attempts to comply, with this authorization. I waive any right that I may have to inspect any information provided about me by any person or organization identified by me in this application. Should my application be accepted, I agree to refrain from unscriptural conduct in the performance of my services on behalf of the church. I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding agreement which I have read and understand.