Professional Membership Application

If you would like to mail or fax your application, please click here.

All fields with an asterisk * and colored red are required. IF NOT APPLICABLE, indicate N/A.

Contact Information

*Email Address:

*Daytime phone:

*Evening phone:

URL:

Fax: (call first? yes no)

*Mailing address: (Your mailing address will not be given to ANYONE.)

*City

*State/Prov

*Zip/Postal Code

*Country

Coaching Information

*Coachingfull time part time

If part time, what is your full time profession? 

*What was your profession/career prior to coaching? 

*Are you presently enrolled in Coach Training? yes no

If yes: I am enrolled in (name of school) Coach Training Program

*I graduated from  (name of school) Coach Training Program date

*I hold the following coaching designations/certifications: 
(please list the certification, the name of granting organization, and the date) 

*If you do not have specific coach training, describe your understanding of professional coaching:

*Do you presently or plan to coach minors?YesNo

Christian Information

*Complete the following sentences, according to your beliefs: 

a) I believe that Jesus Christ is:

b) My Christian life/experience is: 

Reference: (name and contact information of pastor, church leader, or person who knows you well as a Christian.)

*Name: 

*Position: 

*Phone: or *Email:

*Were you invited to join CCN by a member?  If so, who?

What else would you like us to know? 

AGREEMENT

          ***   PLEASE BE PATIENT ***
as you are taken to secure server for payment information.

VISA and MASTERCARD are accepted.