Join a Mentor Group

Personal Information
*Gender: Male  Female
My Title (One Title Only Please):
* My First Name:
My Middle Name or Initial:
* My Last Name:
* My Name as I would like to be Addressed
(One Reference Only Please):
*Year Born (You must be at least 18 to apply):
* Primary Language:
I can also Fluently Speak & Write:
I can also Fluently Speak & Write:
I can also Fluently Speak & Write:
I can also Fluently Speak & Write:
I can also Fluently Speak & Write:

Contact Information
* My Email Address:
* Confirm Email Address:
* Create MentorLink Web Site Password:   (Maximum of 10 Character Password)
* Confirm Your New Password:
* Country Calling Code:

                              *At least one Phone Number is required:
Mobile Phone:   
Home Phone:   
Office Phone:

         Ext  
Skype Name (if you have one):   
* Street Address of Residence:
* City of Residence:
* State / Province of Residence:
* Postal Code of Residence:
* Country of Residence:
* Internet Access: None  Dial-up  High Speed 
Internet Reliability: Poor  Intermittent  Good 
Phone Reliability: Poor  Intermittent  Good 

Your Church or Organization Information
* Your Church or Organization Name:
* Your Church or Organization Ministry Description:
(100 Characters Max)
* Your Personal Ministry Focus:
(100 Characters Max)

If You Are Planning To Attend CapeTown 2010
* Accepted to Capetown 2010: Yes  No 
CapeTown 2010 City Attending (include remotes):
Conference Location Country:

Affirmations and Actions
* Where a local group is available, I am willing and able to travel up to: 0 mi.  5 mi.  10 mi.  45 mi.  60 mi. 
* I would like to be a part of either a distance or a
local (where available) mentoring group and go
through the “Leaders Follow Jesus” materials: 		Yes  No 
* I affirm the deity of Jesus: Yes  No 
* I affirm the Lausanne Covenant: Yes  No 
* I affirm the MentorLink Transformational Virtues: Yes  No 

* Indicates Required Fields
  



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