PLTS Racial Justice and Faith Certificate Application

The information on this form is used for public/directory information and academic databases. The information is intended for internal institutional use and will not be shared publicly except where noted.

Program Information

Program

Desired Start Date

This program offers the option to enroll in all 4 courses for the certificate at once, or allows you to initially enroll in a single course. Please select the option you plan on pursuing.

Enrollment

4-Course Certificate

1 Course Only

Contact Information

First Name

Last Name

Mailing Address

Country

Street

City

Region

Postal Code

Cell Phone #

Please send me important messages via text message (standard message charges will apply).

Yes

No

Other Phone #

Email Address

Personal Information

Gender

Ethnicity

Birthdate

Country of Origin

Highest Level of Education Completed

Denomination Information

Religious Denomination or Affiliation (leave blank, if none)

Synod (leave blank if not affiliated with ELCA)

Clergy

Personal Statements

Why are you interested in pursuing studies in Racial Justice and Faith?

What background and experiences do you bring to this topic?