Certification Referral Enrollment

Certification Enrollment Form (Alumni)

A completed enrollment form and payment (either payment in full or payment plan contract initiated with a down payment) confirms your enrollment in the program. If you select to pay by monthly payment plan, complete the form and a contract will be sent to you later.

The cohort I've been accepted into is:(Required)

New York City - In Person, Winter 2025

Houston - In Person, Winter 2025

Online - Virtual, Winter 2025

Name(Required)

First Last

Email(Required)

Phone(Required)

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Church Organization/Ministry Name(Required)

Emergency Contact Person(Required)

Relationship to contact person(Required)

Spouse/Significant Other

Parent

Sibling

Adult Child

Friend

Emergency Contact Mobile Number(Required)

Demographic Information

Date of Birth(Required)

MM slash DD slash YYYY

Marital Status(Required)

Single

Engaged

Married

Divorced

Widow

Education Background: What is the highest level of education that you have completed?(Required)

High School

Some College/Trade School/Technical School

Graduated with a 2-Year Degree

Graduated with a 4-Year Degree

Post Graduate Level Work

Post Graduate Degree

Ethnicity(Required)

Asian/Asian American/Pacific Islander

Black/African American/African

Hispanic/Latino/Latina

Native American/American Indian/Indigenous

White/Caucasian/European

Multi-Racial or Multi-Ethnic (2 or more races or ethnicities)

Payment Plan

The total program cost is $1,645 if paid in full or $1,735 if paid by payment plan. The deposit amount is $50 (non-refundable). Your $50 payment will be deducted from your total fees. There are 3 payment options: 1) Pay in full 2) Pay Monthly payments; or 3) Trimester payments. What is your preferred choice?*(Required)

Pay in full (gives a 5% savings)

Monthly Payments

3 Trimester Payments

Certification Program Covenant Agreement

I gracefully recognize the sovereign timing of God that I’ve been afforded the opportunity to be a part of this cohort. The cohort consists of a dynamic, mosaic, and compassionate group of youth ministry leaders that desire to build competencies in key areas such as leadership, self-awareness, spiritual rhythms, strategic planning, ministry organization, discipleship, community engagement, and more. With that, I enter into covenant agreement with Urban Youth Workers Institute, the Program Facilitators, and fellow Cohort members that:

I will attend all of the classes and be engaged during discussions and activities (including completing pre-work and post-work assignments).
I will help to create a safe environment, whereby others can feel comfortable and open to share personal experiences without feeling judged. This includes treating what I hear with confidentiality and a level of privacy that models Kingdom leadership.
I will respect and value the diversity of thoughts, ideas, and opinions of others and understand class time is not a time for debating or convincing others of my position or opinion (i.e., denominational theologies, ideologies, political views, social views, etc.)
I will not use this cohort as a market to promote or sell any services or goods.
I will pray for my cohort and all of the cohorts in the other cities, as well as future leaders that will come through this process.

By typing my full name, I adhere that it serves as a signature and agreement to abide by the Covenant Agreement.(Required)

Check all boxes to indicate you have read and agreed to each statement.(Required)

I commit to regularly attending the Certification Classes, and I understand that if I accumulate more than 2 absences I may be dismissed from the program and not eligible to receive an Urban Youth Ministry Certificate.

I understand that my enrollment will be final only after I pay in full or complete a Payment Plan contract.

I understand that there is a fee of $35 for failed auto-payments.

I understand that multiple delinquent payments may result in dismissal from the program.

Deposit Payment(Required)

I will pay the $50 Deposit now

Someone else is paying

Deposit

Price:

Total

First & Last Name of person responsible for payment:

Title of person responsible for payment:

Phone number of person responsible for payment:

Email address number of person responsible for payment:

Consent

I understand that my enrollment is NOT complete until payment is received by my organization.

Credit Card

Card Details

Cardholder Name

Consent for Media Release

During the program, we will take group pictures, and random candid shots to capture the experience of the cohort. Additionally, each month you will be asked to record and submit a video journal of what you learned in class. Your participation in the UYWI Certification Program grants UYWI and their successors licensees, and assigns irrevocable right (but not obligation) to use participant’s name, likeness, voice, photograph and/or video image at its sole discretion in part or in whole, in its publications, print media, and electronic media (including social media & the Internet). This consent is given in perpetuity, and does not require prior approval by me. Your signature below gives consent.

Signature. By typing my name in full again, I understand it serves as a signature that the information provided in this entire document is correct and accurate. *(Required)

Finally, what is your T-shirt size(Required)

We will be ordering T-shirts for all cohort leaders and want to ensure we are ordering your correct size. The color is Heather Sapphire. Ladies may choose between a Unisex shirt or a Women’s (cut) shirt. Please indicate your preference below? See the difference between the Unisex and Women's cut by clicking on the links. Please order the shirt for yourself and not to give to someone else. We will take a group picture with everyone wearing their shirt. Unisex: https://www.ssactivewear.com/p/gildan/5000 Women's: https://www.ssactivewear.com/p/gildan/5000l

Women's S

Women's M

Women's L

Women's XL

Women's 2XL

Women's 3XL

Unisex S

Unisex M

Unisex L

Unisex XL

Unisex 2XL

Unisex 3XL

Unisex 4XL

Unisex 5XL

Certification Enrollment Form (Alumni)

Demographic Information

Payment Plan

Certification Program Covenant Agreement

Consent for Media Release

Connect with us

Urban Youth Workers Institute

Sign-up to our eNews

DON'T GO!

Sign-up and get access to our FREE digital resources.