Parent/Emergency
Contact Full Name:

Address:

Address 2:

City, State, & Zip:

, AL AK AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY    

Phone:

() -   

Event Planning

Public Speaking

Organization/Administration

Debate

Teaching

Music

Evangelism

Language

Other  If other, please specify:

Please write a brief statement of how you came to know Jesus Christ personally.

Describe your walk with God:

What is your understanding and attitude toward taking the initiative in sharing the gospel?

Are you willing to be trained in evangelism?  Yes No

I share my faith:   Weekly Monthly Occasionally Seldom Never

E-Mail Address of Spiritual Reference: 

E-Mail Address of Faculty Reference:  

Do you have a police or prison record?  Yes No

If yes, explain the details below:

In the last 12 months, have you used narcotics, hallucinogens, drugs not prescribed by the physician, or have you struggled with alcohol abuse?     Yes No

If  yes, explain the details below:

In the last 12 months, have you had a relationship that would not be considered above reproach, eg., light/heavy petting or sexual intercourse, or have you been involved in a homosexual encounter/relationship?  Yes No

If yes, explain the situation below.  Explain the steps you have taken to change that involvement. 

Is anyone holding you accountable in this area?  Yes No

In the last 12 months, have you struggled with an eating disorder?  Yes No

If yes, explain the situation below.  Explain the steps you have taken to change that involvement. 

Is anyone holding you accountable in this area?  Yes No

Do you have any physical conditions which may limit you (such as serious allergies,
requiring medication, back problems, limited mobility, extremely poor eyesight, hearing
loss, etc) or an emotional/psychological issue (such as phobias, emotional outbursts,
schizophrenia, depression, etc.)?  Yes No

If yes, please specify below:

If you are on medication, can you bring enough to last for the entire project?  Yes No

Are you currently or have you been under a doctor's care for any reason not indicated above?  Yes No

If yes, please explain below:

List your specific reasons for desiring to go on this overseas trip.

How would you like to see yourself grow through this project?

Have you discussed with your parents your desire to go on this project?  Yes No

What was their response?