Covenant Discipleship Request Form

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First name*

Last name*

Name of Spouse (First & Last Name/ Nicknames)

Primary Email*

Spouse's Email

Phone*

Address*

Wedding Date

Date of Salvation*

Date of Water Baptism*

Date of Holy Spirit Baptism with evidence of speaking in other tongues.*

Briefly share your Salvation Story (You may include your water and Holy Spirit Baptism stories)*

Date of Spouse's Salvation

Date of Spouse's Water Baptism

Date of Spouse's Holy Spirit Baptism

Briefly Describe your Spouse's Salvation Story (You may include your water and Holy Spirit Baptism stories)

What is the Name of your Home Church; Local Pastor; and how long have you attended?*

Do you attend church services regularly?*

Yes

Have you saught and received Discipleship before?*

Yes - Individual

No - Individual

Yes - Couples

No - Couples

How long was your previous session?

Reason for termination.

Please describe the reason that you are seeking Covenant Discipleship (Inter/IntraPersonal, Financial, Pre-Marital, Marital, other).*

What goals do you hope to achieve through Covenant Discipleship?

By signing below, I/we hereby release and forever discharge and hold harmless Glorious Jones Ministries aka New Life 2012, Inc. and the directors, pastors, ministers thereof, from any liability, claims, or demands for personal injury, sickness or death. I/we understand that the discipleship I/we receive is not from LICENSED PSYCHOLOGIST OR PSYCHIATRISTS. I/we simply receive discipleship based on the Word of God; and an opportunity for prayer led by the Holy Spirit.

Covenant Couples, please upload a copy of your Marriage Certificate

Signature

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Covenant Discipleship Fees - Please select one.

Individual Discipleship100 US$

Covenant Couples Discipleship200 US$

IFOM Covenant Couples Discipleship50 US$

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