Student Application
Please fill out the following application. (All sections must be filled out.)
I. Student Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student Phone Number
Please enter a valid phone number.
Parent Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth:
*
-
Month
-
Day
Year
Date
Gender:
Male
Female
T-Shirt Size:
XS
S
M
L
XL
XXL
XXL
Citizenship:
Yes
No
Primary Language:
English
Ukrainian
Russian
Other
Valid Driver's License:
Yes
No
Upload a photo of your driver's license below.
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II. Medical Disclosure Form
(All medical and personal information will be kept confidential)
Primary Care Physician:
Alternate Contact:
Office Phone:
Please enter a valid phone number.
Do you have any allergies?
Yes
No
If Yes, please list below:
Do you take medication(s) for your allergies:
Yes
No
If Yes, please list below.
Do you have Asthma?
Yes
No
If Yes, will you carry a rescue inhaler during school session?
If Yes, do you need staff help to use that rescue inhaler?
If Yes, what triggers the asthma?
Activity Restrictions:
Physical Handicaps:
Dietary Restrictions:
Medical History:
ADD/ADHD
Anemia
Appendicitis
Asthma
Autism
Bleeding/Clotting Disorder
BP Issues
Bronchitis
Emotional/Behavioral Issue
Concussion
Cramp, Severe
Seizures
Diabetes
IBS
Dislocations, Sprains, or Strains
Eating Disorder
Epilepsy
Migraine Headaches
Fainting or Dizziness
Heat exhaustion
Hepatitis A, B, or C
Heart Disease or Defect
Hernias
Joint or Muscle Pain
Motion Sickness
Pneumonia
Skin Conditions or Rashes
Sleepwalking
Cancer
Autoimmune disorder
Name any injuries, illness, or disabilities not mentioned and the year of occurrence:
Medications:
Please list all medications (including over-the-counter or nonprescription drugs) being taken regularly.
Medication
No medications taken regularly
Takes medications regularly
Medication:
blanks
Dosage:
blank
Times taken daily:
Medication:
blanks
Dosage:
blank
Times taken daily:
Medication:
blanks
Dosage:
blank
Times taken daily:
Parent Signature
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Medical Insurance
Does the student have medical insurance?
Yes
No
Insurance Carrier: Policy Number:
Insurance Carrier's Phone Number
Please add a photo of a medical card.
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Bible School Participation:
Does the student have any physical, emotional, mental, or physiological limitations that would affect your participation in any of our scheduled activities?
Yes
No
If yes, please fully describe such conditions or limitations below:
By signing below, I acknowledge that I have completed this Medical Disclosure form accurately, truthfully, and to the best of my knowledge. I further warrant and represent that if any of the information contained in this form changes at any time, I will immediately provide Philadelphia Bible School with such updated information. I acknowledge that the program will handle medications as described and that information on this form will be shared with administration on a need-to-know basis. All medical and personal information will be kept confidential to the extent required by law.
Parent's Signature
Student's Signature
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III. Family Information/Emergency Contact
Father's Name
First Name
Last Name
Father's Phone Number
Please enter a valid phone number.
Mother's Name
First Name
Last Name
Mother's Phone Number
Please enter a valid phone number.
Emergency Contact #1:
First Name
Last Name
Contact #1: Phone Number
Please enter a valid phone number.
Emergency Contact #2:
First Name
Last Name
Contact #2: Phone Number
Please enter a valid phone number.
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IV: Spiritual Information: (Student please answer)
Name of Church:
Church Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pastor's Name:
First Name
Last Name
Pastor's Phone Number:
Please enter a valid phone number.
What denomination do you belong to?
Is Jesus Christ the Lord and savior of your life?
Yes
No
In what language do you read the Bible?
English
Ukrainian
Russian
Other
What version of the Bible do you read?
ESV
NIV
NKJV
KJV
NASB
NLT
Other
Rate your knowledge of the Bible:
Below Average
Average
Above Average
Have you read the entire Bible at least once?
Yes
No
Are you currently involved in your local church?
Yes
No
Do you have musical abilities?
Sing
Play Instruments
No
What Instruments do you play?
Do you have experience in the following? If yes choose all that apply below.
Preaching
Leadership
Worship Group Singing
Solo Singing
Choir Singing
Tech Set-up in the Church
Sunday School Helper
Other
If you chose other, explain:
Practical Electives:
Please select a practical elective in which you would like to participate and learn from a knowledgeable instructor. Select your top 3 options. We cannot guarantee that you will get your top choice. Groups fill up on first come-first serve basis.
Teaching Children & Sunday School
Preaching/Sharing Testimony/ Public Speaking
Choir Conducting
Leading Worship/ Group Singing
Evangelism/ Witnessing Ministry
Apologetics
Hosting/leading a Bible Study group
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V. Background Information:
Have you ever been:
Arrested?
Convicted?
Expelled from School?
Do you currently use:
Tobacco/Weed/Vapors?
Alcoholic Beverages?
Drugs?
Is there anything we may need to know in regards to you legally(probation/parole)?
VI. Self Evaluation:
Main Goal for attending Bible School:
What theological topics are you most interested in?
What is your favorite activity?
What do you do during your free time?
What are some of your skills and talents?
Please describe what you would like to improve during Bible School:
Please honestly evaluate yourself on the following qualities:
Bad
Not too Good
OK
Good
Very Good
Character
Motivation
Leadership
Independence
Responsibility
Timeliness
Self-Control
Acceptance of others
Relationship with parents
Relationship with friends
Relationship with authority
Relationship with God
Relationship with myself
Knowledge of God/His Word
Ability to make good decisions
Ability to overcome stress
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VII. Personal Statement:
Please write a one page statement which includes your testimony (the story of your conversion to faith and repentance) and why you would like to come to Bible School.
Write Below:
Student's Signature
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VIII. Permission/ Signature's
I certify that all of the information and statements on this application are complete and accurate to the best of my knowledge. I have read and agree to obey and follow all rules, regulations and the schedule of Philadelphia Bible School. In the event that I do not obey and follow all rules, regulations, and schedule of Philadelphia Bible School, my parents and pastor will be notified and I may be asked to leave the remainder of the school without a refund or certificate. In case my application is denied, I will receive a full refund.
Student's Signature:
Participant release/waiver of liability and indemnification agreement
I am the parent or legal guardian of:
First Name
Last Name
who is under 18 years old. In consideration for my child’s opportunity to participate in the EPC Teen Bible School of Evangelical Pentecostal Church, I affirm and agree with the following statements:- My child and I agree to become familiar with all EPC Teen Bible School rules and instructions and to abide by them. I understand that EPC retains the right to suspend or terminate my child’s participation in EPC Teen School if it is believed that the student has failed to comply with any school, activity rules or instructions, or for any other reason in its sole discretion.- My child is physically sound and suffering from no condition, impairment, disease, or other illness that would hinder him/her or others from safely participating in EPC Teen Bible School. It is my responsibility to ensure that my child follows any restrictions, prescriptions, or limitations that apply to my child’s physical condition or state of fitness.- I recognize and fully understand and agree that in the event it becomes necessary for my child to receive medical treatment during his/her participation in EPC Teen Bible School, reasonable efforts will be made to contact the persons listed on my child’s Medical Disclosure form to obtain directions and authorization for such treatment. However, if the person(s) listed cannot be reached, I hereby authorize, direct, and give my full and complete permission to one or more authorized representatives of EPC and/or any advisors, directors, leaders, volunteers, or representatives to seek medical treatment on my child’s behalf, including selecting and authorizing medical professional(s) (including, but not limited to nurses, LPNs, PAs, paramedics, doctors, or dentists) to take such action as is deemed necessary by any attending medical professional. I further give my full and complete authorization to such medical professional to hospitalize, order injections, administer anesthesia, perform surgery, or secure additional necessary medical treatment for my child as necessary and/or appropriate under the circumstances as determined by the medical professional. I further certify that I am willing to assume the risk of any medical or physical condition that my child may have. I further understand and acknowledge that it is my duty to provide accurate and current information of such conditions on my child’s Medical Disclosure Form.- I recognize and fully understand that the insurance coverage listed on my child’s Medical Disclosure form will be used as the sole insurance coverage for him/her in the event medical treatment is needed, and that I (or the responsible party for my insurance coverage) am solely and personally responsible for any payments or charge(s) not covered by such insurance. I further understand, acknowledge, and agree that no such insurance coverage is or will be provided for me by EPC. I understand and agree that if my child does not currently have valid health insurance coverage, none will be provided for him/her by EPC, and that I (or the responsible party for my insurance coverage) am responsible for any and all costs associated with medical treatment that may be required as a result of my participation in EPC Teen Bible School.- I, do hereby grant permission to EPC Teen Bible School to use the image/voice recording of my child as marked by my selection(s) below. Such use includes the display, distribution, broadcast, publication, transmission, or otherwise use of photographs, images, audio recordings, and/or video taken of my child for use in materials that include, but may not be limited to, printed materials such as brochures and newsletters, blogs, videos, and digital images such as those on the teenschool.epcphila.org website. No personal information will be distributed or published without parental permission.- Except where such an exception is prohibited or limited by applicable law, except for any claims, actions, liability, and/or demands (“Claims”) that arise from, are caused by, or result from the gross negligence or willful misconduct of EPC and its affiliates, directors, volunteers, independent contractors, representatives and successors in interest (collectively, “Affiliates”), I hereby release, forever discharge, and agree to hold harmless EPC from any and all claims for bodily injury property damage, wrongful death, loss of services, or otherwise, which may arise out of the mychild’s participation in EPC or which may arise out of my child’s travel to or participation in andreturning from any activity associated with EPC, which may hereafter accrue to my child. ThisRelease/Waiver is understood to also be in effect with respect to, and to include any persons whomay be engaged in, the transportation, hosting, treatment or attending to, or accompanying mychild to any facility for Medical Treatment on or off of EPC property, on the same basis and termsas stated above. I further agree to hold harmless and indemnify EPC from any Claims resulting inany way from my child’s or my acts or omissions.
I certify that all of the information and statements on this application are complete and accurate to the best of my knowledge. Parent or Guardian Signature:
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IX. Pastor/Youth Leader Recommendation
Please provide your pastor's/youth leader's information below. Youth Leader's phone and email are mandatory. Pastor's phone and email are strongly recommended so that we can get in direct contact with them regarding their recommendations. Please reach out to provide as much information as possible-thank you!
Pastor's Name
First Name
Last Name
Pastor's Email (Strongly Recommended)
example@example.com
Pastor's Phone Number
Please enter a valid phone number.
Youth Leader's Name
First Name
Last Name
Youth Leader's Email
*
example@example.com
Youth Leader's Phone Number
*
Please enter a valid phone number.
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X. Application Checklist
Before you send your application, please check for:
Fully completed application
Personal Statement Essay/Testimony
Completed Pastor's Recommendation/ Youth Leader's Application
Copy of Medical Insurance card
Copy of Driver's License (if student has a license)
Student Photograph (Passport Style)
Post Admission Requirements:
Payment is due by May 1st; otherwise, the spot will be forfeited. (Once the application is accepted the payment will be requested.)
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