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Student Application: Bluefields Nicaragua
Your application is personal and will not be shared with any other students. Please be as honest as possible so that we can walk with your in your discipleship process.
Student Name
*
First Name
Middle Name
Last Name
Which School Are You Applying For?
*
Please Select
DTS
English School
Bible School
Gender
*
Please Select
Male
Female
N/A
Date of Birth
*
-
Day
-
Month
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Country
E-mail
*
example@example.com
Telephone Number
Passport Number
Marital Status
*
Single
Engaged
Married
Divorced
Widowed
Name of your Spouse/Fiancé
How long have you been married?
Accompanying Children (names & ages)
Details of past marriages or separations
Emergency Contact
*
First Name
Middle Name
Last Name
Relationship to the applicant:
*
Address
Street Address
Street Address Line 2
City
State / Province
Country
Telephone #
*
Home
Work
Mobile
Church Information
Denomination
Church Address
Street Address
Street Address Line 2
City
State / Province
Country
Pastor's Full Name
Church's Phone Number
Personal Questions
How do your spiritual leaders feel about you doing a DTS?
*
Are you currently in school?
*
Please Select
Yes
No
Highest level of education completed?
*
Work experience for the past 5 years:
*
What job did you enjoy the most? Why?
*
What are some of your talents and hobbies?
*
How do you like to spend your free time?
*
Do you have any past experiences with YWAM? If so, how?
What other missionary organizations have you been involved with?
What types of leadership experiences have you had?
*
Are you a licensed or ordained minister?
*
Please Select
Yes
No
If yes, please describe the details of your license/ordainment
What languages do you speak, and how fluently?
*
Have you worked with people of other cultures, races, or religions? (Describe your experience)
*
Please describe your family of origin and the circumstances of your childhood and teenage years
*
Please describe any adverse issues that have affected you
If your family supportive of you doing a DTS?
*
Describe the events of your conversion and the steps leading up to that time
*
How are you doing in your devotional life?
*
Describe the current status of your spiritual growth
*
Describe your involvement with your local church. How have you used your gifts and abilities?
*
How have you helped others come to know Christ?
*
How did God call you to do a DTS?
*
What do you hope to accomplish through doing a DTS?
*
What are your dreams and visions for the future?
*
What are your top three destinations for outreach and why?
What experiences have you had in being self-reliant and responsible for yourself?
*
How do you think you deal with difficulties?
*
What experiences have you had in adjusting to a different lifestyle?
*
How do you relate in new social settings?
*
Bluefields is a city with a strong emphasis in sensuality. Our concern is that we would not bring you into a place where you may stumble. Therefore, please indicate if you think you may have difficulty with any of the following areas: alcohol, gambling, promiscuity, drugs, occult behavior, pornography and/or tobacco.
*
Do you have any outstanding debts? (if yes, explain)
*
Do you have an other financial commitments?
Do you have all the money required to cover DTS costs? If not, how much do you still need?
*
Have you ever been convicted of a felony? If so, describe in detail
*
Are there any special circumstances or situations we should know about?
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DTS Student Confidential Health Form
What is your blood type?
Height (ft/cm)
Weight (lbs/kg)
Rate Your Health
*
Very Good
Good
Average
Below Average
Do you have any objection to using medical services?
*
Yes
No
If yes, please explain
*
Have you struggled with any eating disorders (anorexic, bulimic, compulsive)?
*
Yes
No
If yes, please explain
*
List all important past surgeries, X-rays, illnesses, injuries, or handicaps and briefly explain (Does this limit you in any way?)
Please describe any special dietary needs (Does this limit you in any way?)
Date of last medical examination
-
Day
-
Month
Year
Date
Do you drink alcoholic beverages?
*
Yes
No
If yes, how often and how much
*
Do you smoke?
*
Yes
No
Are you willing to quit?
*
Yes
No
Are you presently taking any medication?
*
Yes
No
If yes, name of drug / For what ailment or condition?
*
Do you ever have trouble sleeping?
*
Yes
No
If yes, please describe
*
Have you ever had a severe emotional upset, or been diagnosed with a mental illness (depression or other mental illness)?
*
Yes
No
If yes, please describe
*
Have you ever had suicidal thoughts or attempts?
*
Yes
No
If yes, please comment
*
Have you ever used drugs for anything other than medical purposes or abused prescription medication?
*
Yes
No
If yes, when? Name of drug(s)? For how long?
*
Are you pregnant?
Yes
No
If yes, when is your due date?
-
Day
-
Month
Year
Date
Have you been pregnant before?
Yes
No
Have you been tested for HIV?
*
Yes
No
If yes, what was the result?
Have you ever had or do you have any of the following?
*
Rows
YES/NO
Allergic to food
Yes
No
Allergic to penicillin
Yes
No
Allergic to selfonamides
Yes
No
Allergic to serum
Yes
No
Allergic to other
Yes
No
Anemia
Yes
No
Back problems
Yes
No
Broken Bones
Yes
No
Diabetes
Yes
No
Dislocation of Joints
Yes
No
Ear Trouble
Yes
No
Epilepsy
Yes
No
Eye Trouble
Yes
No
Fainting Spells
Yes
No
Gall Bladder Problems
Yes
No
Hey Fever
Yes
No
Head Injury
Yes
No
Heart Condition
Yes
No
Hepatitis
Yes
No
High or Low Blood Pressure
Yes
No
Insomnia
Yes
No
Intestinal Trouble
Yes
No
Jaundice
Yes
No
Kidney Disease
Yes
No
Migraines
Yes
No
Nervous Disorders
Yes
No
Paralysis
Yes
No
Recurring Diarrhea
Yes
No
Rheumatism/Arthritis
Yes
No
Shortness of Breath
Yes
No
Skin Condition
Yes
No
Stomach/duodenal ulcer
Yes
No
Tumor/Cancer
Yes
No
Weakness
Yes
No
Venereal Disease
Yes
No
If yes for any of the above, please explain:
Have you ever had any of the following communicable diseases?
*
Rows
YES/NO
Chicken Pox
Yes
No
Measles (Rubella)
Yes
No
Measles (Rubeola)
Yes
No
Mumps
Yes
No
Pertussis
Yes
No
Scarlet Fever
Yes
No
Tuberculosis
Yes
No
Other (please specify bellow)
Yes
No
If You Selected "Other": Please Specify
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Consent Form: Release of Liability
We do hereby release YWAM BLUEFIELDS, its staff, agents and volunteer assistants from any liability whatsoever arising out of an injury, damage, or loss which may be sustained by said person during the course of involvement with YWAM BLUEFIELDS.
Applicant's Signature
*
(Signature of Parent or Guardian required if applicant is under 18 years of age.)
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Consent for Treatment
In case of emergency, We hereby agree to the performance of such treatment, including anesthesia and surgery, as the attending doctor may deem necessary.
Applicant's Signature
*
(Signature of Parent or Guardian required if applicant is under 18 years of age.)
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Burial Statement
Although it is most unlikely that any YWAM staff or student will pass away during his/her time on the field, it is important to consider this possibility prior to travel abroad. YWAM does everything possible to protect its staff and students while on outreach. In many countries where disease is prevalent, burial may have to take place within 24 hours. If this is the case, the remains would not be able to be returned to the student or staff person’s home country. Additionally, all burial costs and transportation expenses are not the responsibility of YouthWith A Mission, Bluefields, its staff or associates. Therefore in the event of my decease, I give my permission to be buried in the country of service if need be, and absolveYouth With A Mission, its staff and associates from any financial responsibility for burial costs or transportation expenses.
Applicant's Signature
*
(Signature of Parent or Guardian required if applicant is under 18 years of age.)
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Submit Application
TO FINISH THE APPLICATION PROCESS YOU WILL NEED TO HAVE SOMEONE SUBMIT A CONFIDENTIAL REFERENCE
Forward this link to the person you would like to fill out your reference: https://bit.ly/33cFKSl
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