Guidelines - Other Fellowship Transition

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Form 16 Notarized Disclosure Form

Applicant Name:

_____________________________________________________________________

Email address:

_____________________________________________________________________

District:

[__] AP [__] CM [__] HI [__] MV [__] NR [__] SS [__] SM [__] TV [__] TR

Ministerial Relationship Being Requested: [__] Local Pastor

[__] Associate Membership

[__] Elder

[__] Deacon

General Instructions: 

The Candidate is responsible for uploading completed Form and any attachments to the appropriate registrar(s) as directed by the requesting registrar.

Document should be completed not more than 12 months prior to the required interview



Part I: Legal History (¶ 310.2, 324.12, 346.2, 347.2(a) and 347.3(a)of The Book of Discipline, 2016)

[__] Yes [__] No Have you ever been convicted of a felony?

Have you ever been convicted of a misdemeanor?

[__] Yes [__] No Have you ever been accused in writing of sexual misconduct or child abuse? [__] Yes [__] No If you answer “yes” to any of these questions, attach an explanation.

Part II: Chargeable Offenses Have you read ¶2702 of The Book of Discipline 2016?

[__] Yes [__] No Are you chargeable according to ¶2702 of The Book of Discipline 2016? [__] Yes [__] No If you answered yes, attach an explanation.

Part III: The Christian Life

Do you agree, for the sake of the mission of Jesus Christ in the world and the most effective witness of the gospel, and in consideration of your influence as a clergy person, to make a complete dedication of yourself to the highest ideals of the Christian life as set forth in “Our Doctrinal Heritage,” “Our Doctrinal Standards and General Rules,” “Our Theological Task,” and the “Social Principles,” ¶103‐105, ¶160‐166 of The Book of Discipline, 2016?

[__] Yes [__] No

Part IV: Signature I hereby certify that all the information I have provided is true and accurate.

__________________________________________ __________________________ Signature

Date

Subscribed to and sworn before me on this _______________ date of ________________ 20____. __________________________________________ Notary Public Signature Please submit to: [__] The Office of Clergy Services via ClergyServices@holston.org [__] DCOM 1 of 1

Updated: 2021-02

App 08 Application to serve in the Holston Annual Conference as an Other Fellowship (OF) Name:

______________________________________________________________________________ First

Address:

Middle

Last

______________________________________________________________________________ Street

Best Contact # (______)________-__________ [__] Cell [__] Home [__] Work Email:

City

Birthdate:

State

Zip

_________ _________ __________ Month

Day

Year

______________________________________________________________________________

Denomination: ______________________________________________________________________________

District:

[__] AP [__] CM [__] HI [__] MV [__] NR [__] SS [__] SM [__] TV [__] TR

Having been ordained in another denomination, and after discussion with a District Superintendent, I desire to serve in the Holston Conference. I understand that this is a process and I agree to fully participate in the process which will involve submission of documents and written work to the Conference Relations Committee (CRC) and the District Committee on Ordained Ministry (DCOM) to which I will relate. I also agree to undergo medical and psychological assessments required of ministers seeking to serve in the annual conference.

I realize, that my credentials may or may not meet the standards as set forth by the United Methodist Church and that I can serve without full recognition, but that this will limit my ability to vote and hold offices within the Annual Conference. I also affirm that I am not guaranteed an appointment within the Holston Annual Conference, but that I serve on an as needed basis until my credentials are fully recognized and I apply for membership in the Annual Conference. With this in mind….

I [__] do / [__] do not (mark one) currently seek to have my credentials recognized as equivalent with those of the United Methodist Church by the Board of Ordained Ministry.

If I selected that I seek to have my credentials recognized as equivalent with those of the United Methodist Church by the Board of Ordained Ministry I also seek to serve in relationship as a [__] Provisional Deacon (PD) / [__] Provisional Elder (PE) (mark one). _____________________________________________ Signature

________________________________ Date

District -- Report of DCOM Action: Date this person met with the DCOM: __________________________ The DCOM [__] does / [__] does not recommend this person for an Other Fellowship Appointment. If not recommended please list reasons: ______________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Please submit to: [__] The Office of Clergy Services via ClergyServices@holston.org [__] DCOM 1 of 1

Updated: 2021-12

THE UNITED METHODIST CHURCH MEDICAL SUMMARY REPORT OF MINISTERIAL CANDIDATE Form 103 Candidate’s Name: _____________________________________________________________ To the Board of Ordained Ministry: Please indicate here, the name/address of the board officer who will receive this report.

Name: Address:

Holston Conference Center % Brandy Williams PO Box 850, Alcoa, TN 37701-0850 CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION – COMPLETED BY CANDIDATE

Candidate Name: _____________________________________

Birth Date: _______________________

I hereby authorize and direct ______________________________________ (physician) to disclose to the ______________________________ (annual conference) Board of Ordained Ministry the following information with regard to the records of ______________________________ (candidate) for the purpose of evaluation by The United Methodist Church for entrance into ministry.

I, the undersigned, understand that I may revoke this consent at any time except to the extent that action has been taken in reliance upon it. This consent will expire sixty (60) days after the date treatment is terminated unless another date is specified.

I understand that the information requested may be disclosed from records whose confidentiality is otherwise protected by federal as well as state law. Any of the above requested information may include results of alcohol/drug (substance) abuse and/or diagnosis and treatment of psychological disorders, as well as HIV status.

To the party receiving this information: This information has been disclosed to you from records whose confidentiality is protected by federal law. Federal regulations (42 CFR Part 2) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient for this purpose.

Signature of Candidate

Date

Witness

Date

SUMMARY REPORT – COMPLETED BY PHYSICIAN Comments for physician: Complete the summary report. The United Methodist Church assumes you are completing this information based on a current physical examination of the candidate. Screening guidelines are provided for reference as needed.

This person is a candidate for ministry in The United Methodist Church. Among other requirements, this includes being able to typically work a full‐time week – with periodic weeks requiring longer work hours.

Those serving in ministry will encounter situations that require the ability to cope with conflict and stress.

Job‐related tasks range from office work and traveling from site to site to communicating with and relating to a variety of people and managing multiple tasks simultaneously, among other responsibilities.

Candidate’s Name: _____________________________________________________________ Date of Physical Exam: __________________________________________________________ Check One: ____

Based on the physical exam I completed, this candidate appears to be healthy. I have no concerns about his/her physical fitness for ministry.

_____

Based on the physical exam I completed, this candidate has some health concerns that are summarized below.

Summary of Concerns:

Typical treatment(s) for this condition could potentially include (medication, surgery, lifestyle modification, intervention by specialist, frequent monitoring, etc.):

Questions to ask, or conversation that a committee might have, to address these concerns could include:

Examining Provider: Address: Phone: Fax: Signature:

Date:

STAMP

EXAMINATION STANDARDS* As a part of the ministry application process, The United Methodist Church requires each candidate to “present a satisfactory certificate of good health” by a physician on the prescribed form. Disabilities are not to be construed as unfavorable health factors when a person with disability is capable of meeting the professional standards and is able to render effective service…. (The Book of Discipline, ¶¶ 315.6c, 324.8, 347.3, 357.7, 355.3, 368.5).

The following lists show standard screening practices to be considered in an assessment of physical health.

Additionally, the physician may choose to make recommendations to the candidate as needed. While the candidate’s physician should make the final determination regarding the need for specific medical tests as related to the overall health and needs of the candidate, The United Methodist Church seeks a summary report from the physician upon completion of a physical examination of the candidate that provides an assessment of the candidate’s physical ability to perform the required work of ministry.

NOTE: DO NOT RECORD SCREENING RESULTS ON THIS FORM. Screening Height and weight (periodically) Blood pressure Alcohol and tobacco use Depression (if appropriate follow‐up is available) Diabetes mellitus (patients with hypertension) Dyslipidemia (total and HDL cholesterol): men ≥35 y; men or women ≥20 y who have cardiovascular risk factors; measure every 5 y if normal Colorectal cancer screening (men and women 50‐75 y) Mammogram every 1 to 2 y for all women ≥40 y. Evaluation for BRCA testing in high‐risk women only.

Papanicolaou test (at least every 3 y until age 65 y) Chlamydial infection (sexually active women ≤25 y and older at‐risk women) Routine voluntary HIV screening (ages 13‐64 y) Bone mineral density test (women ≥65 y and at‐risk women 60‐64 y) AAA screening (one time in men 65‐75 y who have ever smoked)

Counseling—Substance Abuse Tobacco cessation counseling Alcohol misuse: brief behavioral counseling; alcohol abuse: referral for specialty treatment

Counseling—Diet and Exercise Behavioral dietary counseling in patients with hyperlipidemia, risks for CHD and other diet‐related chronic disease Regular physical activity (at least 30 minutes per day most days of the week) Intensive counseling/behavioral interventions for obese patients

AAA = abdominal aortic aneurysm; BRCA = breast cancer susceptibility gene; CHD = coronary heart disease. * Based on recommendations from the U.S. Preventive Services Task Force.

Key Points 

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The U.S. Preventive Services Task Force recommends routine periodic screening for hypertension, obesity, dyslipidemia (men ≥35 years), osteoporosis (women ≥65 years), abdominal aortic aneurysm (one‐time‐screening), depression, and HIV infection.

The U.S. Preventive Services Task Force recommends routine periodic screening for colorectal cancer (persons 50‐74 years of age), breast cancer (women ≥40 years), and cervical cancer.

The U.S. Preventive Services Task Force recommends that all pregnant women be screened for asymptomatic bacteriuria, iron‐deficiency anemia, hepatitis B virus, and syphilis.

The U.S. Preventive Services Task Force recommends against screening for hemochromatosis; carotid artery stenosis; coronary artery disease; herpes simplex virus; or testicular, ovarian, pancreatic, or bladder cancer.

Outside of prenatal, preconception, and newborn care, genetic testing should not be performed in unselected populations because of lower clinical validity; potential for false positives; and potential for harm, including “genetic labeling.”

For patients for whom genetic testing may be appropriate, referral for genetic counseling should be provided before and after testing.

A human papillomavirus vaccine series is indicated in females ages 9 through 26 years, regardless of sexual activity, for prevention of cervical cancer.

A single dose of tetanus‐diphtheria–acellular pertussis (Tdap) vaccine should be given to adults ages 19 through 64 years to replace the next tetanus‐diphtheria toxoid (Td) booster.

A zoster (shingles) vaccine is given to all patients 60 years and older regardless of history of prior shingles or varicella infection.

Asymptomatic adults who plan to be physically active at the recommended levels do not need to consult with a physician prior to beginning exercise unless they have a specific medical question.

Smoking status should be determined for all patients.

Patients who want to quit smoking should be offered pharmacologic therapy in addition to counseling, including telephone quit lines.

Routine screening is recommended to identify persons whose alcohol use puts them at risk.

For management of alcohol abuse and dependence, referral for specialty treatment is recommended; for management of alcohol misuse, brief behavioral counseling may be useful.

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Clues for chemical dependency include unexpected behavioral changes, acute intoxication, frequent job changes, unexplained financial problems, family history of substance abuse, frequent problems with law enforcement agencies, having a partner with substance abuse, and medical sequelae of drug abuse.

Condom use reduces transmission of HIV, Chlamydia, gonorrhea, Trichomonas, herpes virus, and human papillomavirus.

It is important to ask about domestic violence when patients present with symptoms or behaviors that may be associated with abuse.

When an abusive situation is identified, address immediate safety needs.

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BIOGRAPHICAL INFORMATION FORM Form 102 Name: _______________________________________________________________________________ First

Middle

Last

Address: _____________________________________________________________________________ Street

City

State

Zip

Cell Phone: (_____) _______________________ Other Phone: (_____) __________________________ Sex: Male

Birth Date: ____________________________________

Female

E-mail:_______________________________________________________________________________ Ethnic Origin: Asian

African American/Black

Hispanic/Latino

American Indian

White/Caucasian

Native Hawaiian/Pacific Islander

Other:

Conference: _________________________________ District: __________________________________ Local Church: ________________________________________________________________________

Church Address: ______________________________________________________________________ Street

City

State

Zip

Briefly describe your involvement in your local church, such as your leadership positions, groups you enjoy, church activities, etc.

www.bomlibrary.org Candidacy/Conference Relations Forms, 2017-2020

Describe your church involvement in activities beyond your local church, such as district or annual conference work, church camps, workshops, outreach, etc.

Educational Background High School College Graduate School Theological Seminary Course of Study Adv. Course of Study Marital Status:

Dates Attended

Yr. 1

Yr. 2

Yr. 3

Yr. 4

Degree or # of Credit Hours

Yr. 5

Credit Hrs: Single (never married)

Widowed

Married (first marriage)

Separated

Married (second marriage or more)

Divorced

If married, please indicate your spouse’s information.

Name: _______________________________________________________________________________ First

Middle

Last

Birth Date: _________________________________ Marriage Date: ____________________________

Spouse’s Occupation: ___________________________________________________________________

Your children, if any: Child’s Name

www.bomlibrary.org Candidacy/Conference Relations Forms, 2017-2020

Date of Birth

Sex/Gender

Education

Additional dependents, if any: Dependent’s Name

Date of Birth

Sex/Gender

Education

Describe your community involvement and volunteer work, such as participation in community organizations, social clubs, service agencies, and other non-church-related volunteer service:

Your childhood family and other significant relatives: Name

Relation

Age

Father Mother

www.bomlibrary.org Candidacy/Conference Relations Forms, 2017-2020

Marital Status

Education

Sex/Gender

Occupation

Work Experience: (current employment, previous employment, and military experience, if any.)

Have you previously served as a local pastor, diaconal minister, deacon, or elder in The United Methodist Church?

Yes

No

Conference Relationship

If Yes, What Conference? __________________________________________________ DATE

Diaconal Minister Local Pastor

DATE Provisional Member Deacon in Full Connection Elder in Full Connection

Associate Member

Have you had a change in clergy relationship with a conference of The United Methodist Church?

Yes

No

Change in Conference Relationship DATE Discontinuance Leave of Absence Medical Leave Termination by Annual Conference Action

DATE Administrative Location Honorable Location Retirement Withdrawal

Note: If additional space is needed please use a separate sheet of paper and attach this form.

www.bomlibrary.org Candidacy/Conference Relations Forms, 2017-2020

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