Community Service Chaplain Basic Training Course

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                    Basic Chaplaincy Training Seminar
                                   REGISTRATION FORM
                                     June 6 - 10, 2011
                             Pentecostal Theological Seminary
                                   Cleveland, Tennessee

Name: __________________________________________                         Date: ______________
Address: ______________________________________________________________

Phone: __________________________ Mobile: _____________________________
E-Mail: __________________________ Fax: _______________________________
Area(s) of chaplaincy interested in or now serving: __________________________
Cost of Seminar: $295.00 ($360.00 for husband/wife couple). Registration Deposit Fee: $75.00
(nonrefundable). Registration fee is applied toward the total cost of the course and Course
Manual and must be enclosed with this Registration form.
Registration Deposit Fee enclosed: Yes___ No____.
I am a pastor / lay worker / law enforcement officer / counselor / other: _____________________.
Are you currently certified as a Community Service Chaplain? Yes / No
Are you seeking graduate or undergraduate credit? Yes / No (If yes, circle which credit)
Are you currently enrolled in a graduate or undergraduate school? Yes / No
NOTE: For undergraduate/graduate credit, you must be enrolled in a COG school.
Cost for COGTS (3 hours), Patten University or Lee University CAPS (2 hours) credit is
the applicable tuition/registration fee plus CSC manual ($40.00).
NOTE: Please make all checks payable to the Chaplains Commission. Sorry, but we are not able to
accept credit card payments. Dress is casual; not shorts.
NOTE: Classes begin Monday morning at 8:00 AM. Lodging and food are each attendee’s
responsibility. Motel information and Directions are available upon request.

                         Mail or Fax this Registration Form to:
                                   Chaplains Commission
                                        P. O. Box 3330
                                  Cleveland, TN 37320-3330
                                       Ph: 423-478-7033/7706
                                         Fax: 423-478-7954

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