2019 Cohort A-pilot programAPPLICATION

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For in-cohort use only, please add your photo to this application

by selecting this photo. (double click on it) In the toolbar “replace image” will appear as an option,

click that and follow the instructions.

Name: ___________________________________________________________________

Your position and name of your church: ________________________________________ Vineyard church ID number _____________ Regional Leader’s name ________________

Affinity group applying for: Bi-vocational La □ □ Viña Planter Sage Women□ □ □

Cell phone _________________________ Email address _______________________ Address __________________________

____________________________□ I am available to attend the inaugural retreat in Chaska, Minnesota, April 25-28, 2019.

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Demographic QuestionsGender: Male Female□ □Age Range: 20-30 31-40 41-50 51-60 61-70 71+□ □ □ □ □ □Race: Asian/Pacific Islander Black Caucasian Hispanic Mixed Prefer not to specify□ □ □ □ □ □

Size of your congregation: under 50 51-100 101-200 201-400 401-1000 □ □ □ □ □ 1001□ +

Position of service: I am a stand-alone senior pastor□ I am a co-senior pastor□ I am a female senior-level leader looking toward pastoring□

Highest Education Level Completed:

High School diploma Some college 2-year degree program 4-year BA/BS degree □ □ □ □ M.A./M.S./M.Div degree post-graduate degree □ □

Additionally, check if any of your academic experience was theological or divinity related.□ □

Previous Experience with a Mentor, Coach, or Spiritual Director: Check all that apply. In the column on the right please share about your experience. You could include names of your mentors, how long you worked with him or her, whether they were in in the Vineyard, and what you thought of the value of that particular experience.

Mentor (imparts experience, skills and □information)

Coach (assists you in dreaming, goal-□setting, and accomplishing your vision)

Spiritual Director (accompanies and co-□discerns the presence and activity of God)

___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________

General QuestionsWhen/where did you start in the Vineyard? ________________________________________________

How long have you served in your current position? ________________________________________

Who are the five people closest to you? ___________________________________________________

___________________________________________________________________________________

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Here’s how I describe my personality: (If helpful, you may use language from Meyers-Briggs, DISC, Enneagram, etc., if known). ___________________________________________________________

The way I learn best is: _______________________________________________________________ ___________________________________________________________________________________

On a Likert scale of 1-5, please place an x in the box that describes your response to the following statements. (Write or type “N/A” in column “3. No Opinion” if the question does not apply to your situation).

1. Highly

disagree

2. Somewhat

disagree

3.No

opinion

4. Somewhat

agree

5. Extremely

agree

I have interest in trans-local leadership

My church is in a healthy place

I am looking for new opportunities & job locations

I like to give back

My friends comment positively on my vulnerability in conversations

I enjoy being bi-vocational

I have a life-calling to full-time ministry

My schedule has some extra time available

Others comment that I could use some work in the area of follow through

I am committed to pastoring my neighborhood and city

I could see myself leading other pastors

I am good at self-assessment

Health is a high priority to me.

I always read & follow the instruction manual.

31.

Highlydisagree

2.Somewhat

disagree

3.No

opinion

4. Somewhat

agree

5. Extremely

agree

I want to finish well as a pastor.

I always accomplish my goals.

I want to cooperate with the Spirit’s formative work in my life.

I like learning things that can help me and others.

I care about the well-being of other pastors and leaders.

I want to pursue health and wholeness.

Others comment on my punctuality.

On a scale of 1-10 please enter a number in the left column to rate your self-assessed abilities over the past 5 years in the following areas:

Was a joyful learner

Committed follow-through

Volunteered for leadership beyond the local church

Served others with a good attitude

Pursued physical health

Pursued mental/emotional health

Pursued spiritual health

Offered my insights to others

Had at least 3 closer friends who are Vineyard pastors

Grew in community with others

Was open & vulnerable with others

Built relationship with other Vineyard pastors in my Area

Listened well to others

Interacted at least monthly with other pastors locally

Grew personally

Grew spiritually

4Was good at self-assessment

Built relationship with other Vineyard pastors in my region

Heard God and obeyed

Took a weekly sabbath rest

Short AnswerFor this short answer section, if you have a printed version and need more room, please clearly mark your extra paper with the question number and add it to your documents when you scan it as a single upload. If entering electronically, just type until you are finished.

1. After discussing the time commitment of this intensive pilot program with your spouse, what are some of the words used to describe his/her feelings about your participation?

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. Discuss how you will make time in your life for the extra hours this Well-being of Pastors Initiative requires of its cohort participants. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. Why do you want to participate?

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_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________

Affirmations

I affirm I have the motivation and emotional space to participate in this 2-year Well-being □of Pastors Initiative.

I affirm that I am eager to benefit from a relationship with a Mentor, Coach, and Spiritual □Director.

I affirm that I am willing to journey with a cohort of fellow Vineyard Pastors in open, honest□ relationship so that we may become healthier, stronger, and wiser.

I affirm again that I am □ able to participate in the inaugural retreat on April 25-28, 2019.

I affirm that my church participates in 3% giving to Vineyard USA. (Non-senior pastors, □please verify with your pastor.)

6 I□

understand that my Regional Leader will be contacted to affirm my participation in this Well-being of Pastors Initiative.

Signature of applicant _____________________________________________________

Signature of applicant’s spouse _____________________________________________

Date of completed application ______________________________________________

Office USE:

Date received _____________________________

Recommendation __________________________

Interview/Follow-up questions/notes: