Licensed Lay Worship Leaders Application for Re-Licensing Oct 4, 2019 | Fundy St. Lawrence Dawning Waters Regional Council Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Primary Phone*Secondary PhoneHome Community of Faith*Home Community of Faith Address* City State / Province / Region Confirmation of Completion of mandatory Boundaries training (or confirmation of being on a waiting list)*Please enter if this is the date completed or date of joining waiting list. Enter date in MM/DD/YY format. (ie "Completed 12/15/97" or "Joined 12/15/97")Confirmation of Racial Justice training.*Please enter if this is the date completed or date of joining waiting list. Enter date in MM/DD/YY format. (ie "Completed 12/15/97" or "Joined 12/15/97")Police Records Check (PRC)*Please enter the year you received your PRC (note that PRCs are good for five years). What continuing training have you completed since you were last licensed?*Reference letter from a someone who has experienced your worship leadership.If you are unable to upload a file please mail directly to Brian DeLong, 1245 Kingsley Road, Birdton, NB E3G 6E1.Max. file size: 64 MB.I am prepared to travel up to the below number hours to serve as LLWLI am prepared to travel up to the below number of kms(return) to serve as LLWLConsent*I am aware of and have considered the LLWL handbook, 2019, and agree to the process outlined therein including outline of eligible services and limitations to these services, training requirements including the need to have taken the Boundaries Training of The United Church of Canada: * Date* MM slash DD slash YYYY Action of the Community of FaithPlease upload a document that the Community of Faith supports your application to be re-licensed as a lay worship leader within Fundy St. Lawrence Dawning Waters Regional Council; signature of representative of Faith Community; and signature of ministry personnel of faith community or pastoral charge supervisor. If you are unable to upload a file please mail directly to Barbara Prowse, 413- 215 Mina Jane Drive, Charlottetown, PEI C1E 3M8.Max. file size: 64 MB.Contact InformationPlease let us know if you give permission to include your name and contact information on the Regional website. Yes, I give permission for my information to be shared on the Regional website No, I do not give permission for my information to be shared on the Regional website Office Use: Action of Fundy St. Lawrence Dawning Waters Regional Council Pastoral Relations Committee: We Approve: Yes / No Date: ______________ Signature (either the Secretary or Chair of Pastoral Relations Committee): _________________________ Signature of Staff Support to MPE: ____________________ Share this:FacebookTwitterLinkedIn