Student Application Form

Name

First NameLast Name

Gender

Date Of Birth

Date

Email

example@example.com

Phone Number

Please enter a valid phone number.

Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Relationship Status

Do you attend a church?

If yes, please provide the name of church and pastor

Educational experience

Have you attended any other programs or internships?

Work Experience (3 maximum)

Please include: occupation, company name, dates employed

Have you ever been convicted of a criminal offence?

If yes, please give particulars below:

How did you hear about Headwaters Discipleship Program and why are you interested in attending?

Do you profess Jesus Christ as your Lord and Saviour?

YesNoI am not sure

How would you describe your current walk with God?

In your desire to grow, describe a way that you see disconnect between your head knowledge of God and how you experience him in everyday life. Give an example.

What do you hope God does in your life during these two months?

What would success in this program look like to you?

Growth within a community setting is a value of Headwaters Discipleship. What excites you about growing within community.

What will be challenging for you about growing within community.

Name a difficult situation that you've gone through and how you responded to it.

How do you usually handle stress, conflict, or change?

Is there anything, in regards to your physical and/or mental health, that may impact your ability to fully participate during the program?

Are you currently receiving counselling or mental-health support?

Do you have any medical conditions or allergies we should be aware of? (This information is needed for food services and precautionary measures. It will not be used in determining your acceptance to the program).

Since participants at Headwaters will be sharing cabins, please tell us about your typical sleep schedule (ie. usual bedtime and wake-up time).

Are you able to commit to the full duration of the program, including all scheduled activities, classes and community responsibilities?

Please provide the name and email address of two references (non-family members, one preferably a pastor/mentor)

*will be contacted by us separately on your behalf

Along with this form, please email us a recent headshot and create a 2-3 minute video describing:

-who is God to you?

-why is Headwaters Discipleship School for you?

-what are you hoping to gain from this experience?

(Create a video on YouTube. Select unlisted. Share the link to: wildgoosecollective@gmail.com)