RMCM Ministries

RMCM Ministries - Program Enrollment Agreement Form
On-Line or By Mail

(All Data Fields Must Be Filled In)
(If enrolling and paying by check or money order or following up with credit card information,
your enrollment payment or enrollment + first course payment must be made/sent within 48 hours)
DO NOT USE THE ENTER KEY TO MOVE BETWEEN THE FORM ENTRY FIELDS.
USE YOUR MOUSE, OR TAB KEY and fill the form out completely. You will find the SUBMIT button at the end of the form

I WISH TO ENROLL IN THE FOLLOWING PROGRAM: (Select One)
Pre-Certification (Lay Counseling Certificate Program) (HS/GED Required For Enrollment)
NCCA Certification Only Program (HS/GED Required For Enrollment)
NCCA License Only Program (Enrolling with a Master's Degree or higher)
NCCA License + AA/BA/MA Program (HS/GED Required For Enrollment)
NCCA NCCA License + BA/MA Program (HS/GED/Min Exper. required For Enrollment)
NCCA License + MA Degree Program (Bachelor's Degree Required For Enrollment)
NCCA License + Doctorate (PhD) Degree Program (Master's Degree Required For Enrollment)
NCCA + 2d Doctorate Degree Program (Doctorate Degree Required For Enrollment)
PERSONAL INFORMATION: (Fill In All Areas)
Your Name:
Street Address (Not P.O. Box): City, State, Zip Code:
Home Telephone Number: Work Telephone Number: Cell Telephone Number: FAX Telephone Number:
Social Security Number: Date Of Birth: (Month, Day, Year) Gender (Male/Female):
E-Mail Address:
Best Time To Contact You:
PLEASE COMPLETE THE FOLLOWING (Fill In All Areas)
I Have Been A Christian (Born Again) For: Years
I Graduated From High School In 19
Do You Have a Associates Degree? (Yes/No) If Yes, Which School, Degree Earned, And Major:
Do You Have a Bachelor's Degree? (Yes/No) If Yes, Which School, Degree Earned, And Major:
Do You Have a Master's Degree? (Yes/No) If Yes, Which School, Degree Earned, And Major:
Do You Have a Doctorate Degree? (Yes/No) If Yes, Which School, Degree Earned, And Major:
Have You Ever Been Convicted Of A Felony? (Yes/No)
If Yes, please explain details
Are You Currently A Commissioned, Licensed, or Ordained Minister? (Yes/No)
If Yes, What Year Were You Credentialed?
Who Issued Your Ministerial Credentials?Denomination?
My Denomination Preference
My Current Occupation
My Spouse's Name (If Applicable)
RESPOND TO THE FOLLOWING: (Check All That Apply)
I am interested in obtaining independent ministerial credentials
I desire to develop a Christian counseling ministry in my church or in my community
PLEASE RESPOND TO THE FOLLOWING ENROLLMENT/EVALUATION QUESTIONS: (Responses Are Required For Evaluation)
1. Why Do You Want To Be A Counselor?
2. What Formal/InFormal Training In Counseling Have You Had?
3. Why Do You Believe That This Program Will Be Of Benefit To You?
4. Do You Have Experience In Dealing With People With Spiritual Or Emotional Problems?
5. What Are Your Goals For A Counseling Ministry?
6. How Do You Know That You Are Called/Suited For A Counseling Ministry?
7. Briefly tell us about your Christian walk, church involvement, and personal testimony:
PLEASE TELL US HOW YOU WERE INTRODUCED TO THE RMCM/NCCA PROGRAMS (Check Only One)
Previously Completed Courses Through RMCM or NCCA TV Ad Radio Ad Christian Magazine Internet ChristianityToday.Com
Referral. Referred By: Other. Describe:
METHODS OF PAYMENT (Initial Cost Information)
The following Are Current Enrollment Costs:
Enrollment + First Course (All NCCA Certification/License + Degree Programs) - $300.00 (April 2008 Special: $250 - Must Enroll/Pay By April 30th, 2008)
Enrollment + First Course (NCCA Pre-Certification (Lay) Program Only) - $200.00
How Will You Be Paying? (Select One)
Check/Money Order By Mail PayPal (Our PayPal Acct is mdesigns@dmrtc.net) Credit Card By Phone Credit Card Online
Payment Amount?
By Mail (Check/Money Order): Within 48 hours or sending this enrollment form, Send your Check/Money Order to: RMCM Ministries, 207 North Spring Street, Odon, IN 47562
By PayPal: Within 48 hours, Send PayPal payment to paypal account: mdesigns@dmrtc.net . Please add $5.00 to your enrollment cost to defray cost of PayPal fees.
Credit Card (By Phone): Leave Credit Card information blank, submit registration form, and within 48 hours call 1-877-885-2735 to provide CC information. Credit Card (Paying Here): Fill Out Credit Card information below, then submit this registration form.
CREDIT CARD PAYMENTS: (If Paying By Credit Card)
Credit Card Company?
Credit Card Account Number? (15 or 16 numbers from the face of your card)
Credit Card Expiration Date (Month/Year)?
Billing Name As It Appears On Your Card
Billing Address For Your Card (Street, City, Zip Code)
I agree to pay all credit card payments in accordance with my credit card company policies and procedures.
I understand that my credit card charge is subject to a 3% processing/convenience fee.
Important Notes: (Read and Agree)

I will be prompted early in Phase I of the program, to provide the balance of the enrollment documentation requirements. In any event, all documentation requirements must be completed by the end of Phase I. For License and degree programs your Ministerial credentials must be provided no later than the end of Phase II. Ministerial credential are required for NCCA licensing.

If paying by check/money order for your enrollment, or enrollment and first course, I understand that I need to immediately follow through with initial enrollment or enrollment & first course payment by mail to reach RMCM Ministries within seven (7) days, unless previous arrangements have been made.

For NCCA Certification/License and Degree programs, there will be additional documentation required after enrollment. These documents include: 1. Copy of highest diploma, certificate or degree earned and related transcript.. 2. Current resume' including any background in counseling or areas of interest in counseling. 3. A recent photo (head/shoulders). 4. Proof of ministerial credentials in the form of a photocopy or official letter (if applicable). 5. Three reference forms (provided by the NCCA with first course). 6. A letter of reference from your pastor, elder, or other church leader. 7. Other documentation as required by RMCM or NCCA. Students will be receive additional instructions and forms with the receipt of the first course, and directed when to submit these documents to RMCM Ministries later in Phase One. These documents are not required for the NCCA Pre-Certification Program, but will be required if the student opts to continue studies to earn NCCA Certification and beyond.

RMCM Ministries will not recommend anyone for certification, licensing, or degrees whose subsequent required documentation are not submitted, or all financial obligations completed in a timely manner.

Once enrolled, candidates will be required to pay for their courses and fees as they go through the program, and when due in accordance with program requirements. Each student is provided a personal program checklist at time of acceptance. Payments may be made by Check, Money Order, Cashier's Check, Credit Card, or PayPal. Payment information and methods are provided again to all students in the student information area.

Your privacy is very important to us. All information received from you is used for internal use only. Personal information is never shared or released to any third parties outside of normal program processing for credentials and degrees, or permission granted in writing.

REFUND POLICY: RMCM Ministries is more than fair to the student who enrolls in the program and then for some reason, needs to discontinue his/her candidacy. We do not believe that an individual should be charged for a service or training not received, therefore, we exceed normal standards with regard to fairness of our students as outlined. a. Enrollment and/or 1st course funds will be totally refunded if the applicant is not admitted into the training program by the evaluation committee, however, once accepted as a candidate, the enrollment fee is non-refundable. If a course is returned to RMCM Ministries in good (resellable) condition within fifteen (15) days of the date it was shipped, the entire tuition for the course, less a $50 restocking fee will be refunded to the enrollee within thirty (30) days from RMCM Ministry's receipt of the returned course materials.

I understand that if paying enrollment, courses or fees by credit card, a 3% convenience fee will be added. PayPal Payments are accepted for courses/fees. A PayPal payment form with processing fees added is available to all students in the student area.
Name and Date:
By printed name above, and checking this statement block, I affirm that I have read. understand, and agree to abide by the requirements of the RMCM/NCCA program, and in this enrollment agreement form. This submission constitutes my official signature and enrollment request.
By pressing the submit button below, your enrollment will be processed electronically with payment, or electronically submitted and followed up with payment sent in separately within 48 hours. Alternately, you may also enroll by mail. Complete the information and Print the completed enrollment form on your printer, OR print the form, and manually fill out the enrollment information, and send your payment within 48 hours, unless other arrangements have been pre-approved.
Our mailing address is:
RMCM Ministries
Center For Counseling & Education
207 North Spring Street
Odon, Indiana 47562
Telephone Number is: (toll free) 1-877-885-2735.