The cohort I've been accepted into is:(Required) Los Angeles - In Person, Fall 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 InformationDate 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 PlanThe total program cost is $1,645 if paid in full or $1,735 if paid by payment plan. The deposit amount is $100 (non-refundable). Your $100 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 AgreementI 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 encourage others in their personal, organizational, and leadership growth. 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 $100 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 CardCard Details Cardholder Name Consent for Media ReleaseDuring 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 Δ
