M28 Registration Form 
Application to enroll with M28 Certificate in Theological Studies
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Full Name (First, Middle, Last)  *
What is your date of birth?  *
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Home Address (Street, City, State, Zip Code) *
Your Best Phone # (w/ Area Code):  *
Email Address: *
ABC Region of your Home Church *
Name of your Local Church  (include City, State) *
Leadership Roles held within your Congregation: Please list all the leadership roles you have held or currently hold in your local church.  *
Prior Education:  *
Prior Education (more information)  Please give name of institutions, year of graduation/completion, and areas of study.  For example:  City High School, 1980, diploma; State University, 1984, BA in Education; Central Seminary, 1996 (incomplete degree - pastoral studies). *
Prior training/education for ministry leadership: Please share any other prior education or training you may have done for ministry leadership.  For example:  CLI, Lay Ministry program, workshops, seminars, etc.  *
Why do you want to enroll in M28? Please write a brief paragraph on what you hope to gain through this program?  What are your goals?  *
Selecting a Mentor: Do you have someone in mind to serve as your student mentor?  Give us their Name, Title or Position, and Education credentials.  For example: 
Yes,  Rev. Jane Smith, Pastor of Bethany Baptist Church - Exodus, IN,  M.Div. 1989 from Northern Seminary. 
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If your enrollment in M28 is approved, it is expected that you will initiate subscription with Kairos University/M28 in the amount of $25/month for academic coursework.  Are you willing a prepared to do this?  (A link will be provided for you by email to initiate your subscription). *
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