December 28, 2016 Online DRVC School of Missionary Disciples 2017 – 2019 Application 1 Personal Information2 Education3 Choose a Site4 Payment 1. Complete and submit this application. 2. Upload or email a photo (passport or similar type) of yourself along with this application. Personal InformationName* First Middle Last Suffix Telephone*Email* Enter Email Confirm Email Mailing Address* Street Address Town ZIP Code Parish*Parish Town*Country of Origin?*What is your primary language?*What other languages do you speak, read or write?*How did you hear about DRVC School of Missionary Disciples? PFI Alumni Pastor Parish Bulletin Office of Faith Formation Website DRVC Website Other If other please tell us where did you hear about DRVC School of Missionary Disciples?Emergency ContactName* First Last Telephone*Have you participated in VIRTUS (The Diocesan Training Program for the prevention, recognition and reporting of child abuse).*I haveI have notStatusMarital Status*MarriedSingleReligiousWidowedSeparatedDivorcedIf married, name of spouse First Last EducationPlease check all that apply to you:* High School Associate Degree Bachelor’s Degree Graduate Studies Religious Education Please specify your Religious EducationDo you participate in any ministries in your parish? Which ones? Catechist Lector Outreach Extraordinary Minister of Holy Communion Ministry of Consolation Youth Group Choir Other Please specifyDescribe your personal strengths as you see them. (Include skills, talents and gifts).*What do you hope to gain from the DRVC School of Missionary Disciples?*Are there any challenges you think you may face during this two year commitment?* Indicate your first and second choice selection from the listing of parish site offerings below: Please note: There is a minimum site requirement of twelve or more participants for a class to be offered for each site. DRVC School of Missionary Disciples Parish Site Offerings Choice 1*SELECT YOUR FIRST CHOICETBADRVC School of Missionary Disciples Parish Site Offerings Choice 2*SELECT YOUR SECOND CHOICETBAUpload photo Please upload a photo (passport or similar type) if you wish to email your photo please email Maria E. Barbieri, firstname.lastname@example.org with the subject DRVC SCHOOL OF MISSIONARY DISCIPLES APPLICATION PHOTO and give your name and contact information. You can also mail you photo along with contact information to Diocese of Rockville Centre, Office of Faith Formation Attention: Maria E. Barbieri PO Box 9023, Rockville Centre, NY. 11571- 9023. Photo uploadAccepted file types: jpg, png, pdf, gif.Please submit your photo in a jpg format Payment Per Year Fee: $ 800.00 includes 27 weekly sessions of instruction, 1 weekend retreat and 2 days of formation per year. Tuition may be paid using one of the following plans. Tuition Plans* Plan A. Tuition of $800 is paid in full by September 15, 2017 Plan B. Tuition is paid in two payments with one-half of the payment due on September 15, 2016 ($400) and the second half of payment ($400) due on the first of February 1, 2018. Plan C. Initial Payment of $200 due September 15, 2017 and $150 per month is due until balance is paid. Please check check one of the following: $150 due October 15, 2017 $150 due December 15, 2017 $150 due November 15, 2017 $150 due January 15, 2018 Sign Your ApplicationName* First Last Date* Check this box if you have reviewed your application and are ready to submit. Checking this box is the same as signing your application.* Yes, I have reviewed my application and understand the terms of this form. For more information, please contact: Maria E. Barbieri, Phone 516-678-5800 ext. 540, email: email@example.com Fax: 516-536-3473 MAKE SURE TO REVIEW AND PRINT OUT A COPY FOR YOUR RECORDS.