PEP CCOP Request Form

Contact Information
*First Name
*Last Name
Preferred Name
*Address 1
Address 2
*City
*State
*Zip
*Phone
*Email
*Are you currently serving a church/hospital/university?
Yes
No
*Church/Hospital/University
*Town/City
*State
*Type of Ministry

Please check all that apply.

Senior Pastor
Solo Pastor
Interim
Assistant/Associate Pastor
New Clergy (3 years or less)
Hospital Chaplain
University Chaplain
Prison/Community Organization Chaplain
Part-time
Retired
A current CCOP Facilitator
Not Currently Serving a Church
Other
*Other
*Geography

Please tell us how far you would travel to a group.

I would travel 30 miles or less
I would travel 30-60 miles
Distance is not a mitigating factor
*I would prefer my meeting to be:
I am open/interested in a meeting virtually (ie., zoom)
I would prefer to meet in person rather than virtually
Other factors you would like us to consider:
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