STUDENT APPLICATION

STUDENT APPLICATION
We are excited you want to join one of our schools! We look forward to walking with you toward greater faith and relationship with God.

This form will take 45 minutes to fill out. Note: There is an application fee of $50 for administrative expenses.
School or Event you are applying for
Year you are applying for
Personal Information
Name

First Name Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Gender
Date of Birth
Your Current Age
Do you have a passport?
Marital Status
Do you have children?
If so, how many do you have?
Will your kids be accompanying you?
Highest Education Completed
Date of completion

Month Day Year
Date
What School/University/College did you attend?
Do you have plans for future studies?
Language Proficiencies
Is English your first language?
Skills & Talents
Please list any occupational skills you have.
Please list any skills or talents.
Finances
How much money have you saved for the school/event fees?
How do you anticipate paying for the school/event fees?
Acknowledgement of Financial Responsibility

Yes, I agree
I understand that payment must be made in full for lecture phase fees upon my arrival, unless otherwise approved by the course leader. Outreach fees must be paid in full prior to my going on the outreach.
Physical & Mental Health
How would you rate your health?
Do you have any illness or condition (past or present) we should be aware of?
Please explain.
Are you presently under a doctor's care for an illness or condition?
Please explain.
Are you currently under any medications?
Do you have any allergies we should be aware of?
Please list and explain your allergies.
Do you have any special dietary requirements?
Do you have any physical impairments, handicaps, or health conditions which require special accommodation?
Have you ever suffered from depression, anxiety attacks, or other mental disorders (Bipolar, Schizophrenia, Manic Depression, OCD, etc.)?
Please explain.
Have you ever had suicidal thoughts or attempted to harm yourself?
Consents & Agreements
Consent of Treatment

Yes, I agree
"Should a situation arise where I am sick or injured and urgently require medical attention, I give to the base director, or his or her delegate the authority to make any decision concerning my immediate treatment, including anaesthetics, medication and operations as in the opinion of the attending physician, are deemed necessary or until as such a time as I am able to make the next decision for myself. I declare that the above named shall not be required to contact my next of kin prior to exercising his/her authority as provided herein. I declare that I shall not hold Youth With a Mission, the base director or his/her delegate, liable for any decision made by him/her for any damage or loss that I sustain as a result of exercising the authority herein granted by me."
Liability Release

Yes, I agree
"I release Youth With a Mission, it's agents, employees and volunteer assistants from any liability whatsoever arising out of injury, damage or loss which may be sustained by myself during the course of my involvement with Youth With a Mission."
Emergency Contact
Name
Relationship to you
Phone Number
References
Pastor/Mentor's Name
Email
example@example.com
Phone Number
Let's get to know you better!
Describe your Christian experience and your present relationship with God.
When and how did you become a Christian?
What areas of your character are you presently seeking God for further development and improvement?
How would you describe the relationships within your family?
Why do you want to do a DTS?
Finishing Up!
Today's Date

Month Day Year
Date
Please upload a recent photo of yourself.

Cancel of
Sign your name

Clear
Once you hit the Submit button, your application will be sent to us and processed. We will get back to you as soon as we can.

Registration Fee

USD

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

STUDENT APPLICATION

Personal Information

Language Proficiencies

Skills & Talents

Finances

Physical & Mental Health

Consents & Agreements

Emergency Contact

References

Let's get to know you better!

Finishing Up!