Culture Shift Application | Church Doctor Ministries

Application Date*

Name*

First Last

Nickname or preferred name?

Email*

Enter Email Confirm Email

Address*

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

Cell Phone*

Church Name, City, State*

I would rate my passion for and commitment to revival in North America as:*

1 = lowest, 10 = highest

I would express my willingness to pioneer extension work and my openness to use very different methods of "doing church" (not changing theology) as:*

1 = lowest, 10 = highest

Please list your dominant spiritual gifts.*

Don't know your spiritual gifts? Take our assessment here: https://onlinenetwork.churchdoctor.org/spiritual-gifts-survey

Are you willing to create a simple next steps action plan to your CDM coach based on what you learn during this immersion experience?*

Yes
No
Not Sure

Priority will be given to those who go on this trip with a team of one, two, or three others. This is so you can process your experience together at home. Is this your intention?*

Yes
No
Not Sure

If you answered "YES" above, please list who will be on your team. Please be sure all of these individuals complete their own applications.

Please add a short biography, no more than 300 words, about yourself. This is used for the team “biography booklet” on the trip.*

All participants must arrive in Hot Springs, Arkansas, by 5:00 p.m. on Thursday, October 23, 2025, without exception, unless you are hindered by a delayed flight. Are you willing to comply?*

Yes
No

Will you have your own vehicle on the trip, and will you be driving yourself (and your team)?

Yes, I will have my own vehicle and will drive
No, I will not have my own vehicle

Please list known food allergies.*

Please list any preexisting health conditions or special requirements that would be important for Tracee to know about while traveling. (You may submit this under a confidential direct email to Tracee, tracee@churchdoctor.org)*

Special requirement could include a special plug for a CPAP machine.

I understand all trip fees paid to Church Doctor Ministries are nonrefundable. If I am unable to participate in the trip for any reason, I may find a replacement traveler from my church or attend a future immersion trip. Replacement travelers must complete the application and be approved by Church Doctor Ministries. I understand these fees do not cover vaccines, testing, or any costs associated with quarantine or medical care needed during my travel. (initial below)

Emergency Contact Name*

First Last

Emergency Contact Relationship*

Emergency Contact Phone*

Emergency Contact Email*

Emergency Contact Address*

Street Address Address Line 2 City State ZIP Code

Please upload a profile picture of yourself

Accepted file types: jpg, png, Max. file size: 256 MB.

Please email a profile picture to info@churchdoctor.org if you don't have it available now or have difficulty attaching it to this form.

Culture Shift - October 2025

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