Internship Application Form
Personal Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Place of Birth:
City
*
State
Country
.
Marital Status
*
Please Select
Single
Engaged
Married
Separated
Divorced
Remarried
Widowed
Father's Name
First Name
Last Name
Father's Phone Number
Format: (000) 000-0000.
Mother's Name
First Name
Last Name
Mother's Phone Number
Format: (000) 000-0000.
Parent's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
In Case of Emergency, Who Should We Contact?
*
Emergency Contacts Name
Emergency Contact Relationship to You:
*
Emergency Contacts Phone Number
*
Format: (000) 000-0000.
Back
Next
Home Church Information
Pastor's Name
*
First Name
Last Name
Your Home Church Name
*
Your Home Church Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Home Churches Phone Number
*
Format: (000) 000-0000.
Are You A Member of this Church?
*
Yes
No
Other
If you are a member, how long have you been a member?
How long has he been your pastor?
*
Please list each ministry you have been involved with in your local church and how long.
*
Back
Next
Employment and School Information
Please list your employment experience. Be sure to include Start/Ending Date, Place of Employment, Position, and Reason for Leaving
*
Name of High School Attended
*
Date of Graduation
*
-
Month
-
Day
Year
Date
Since High School, list any schools, colleges, or universities attended. Please include the name of school, the years of attendance, the year graduated, and any degree or certificate earned.
*
What are you currently studying?
*
Are you requesting that your college grant you credit hours for your internship?
*
Yes
No
Other
Have any disciplinary or administrative actions (i.e. suspension, expulsion) been taken against you by any school during high school or college?
*
Yes
No
If you answered yes to the previous question, please explain
If you are an education major and will be graduating after this school year, would you consider dedicating two years teaching in our Christian School?
*
Yes
No
Not applicable
Other
Do you have any missions experience (short term, summer, etc? If you answer yes to this question, explain what you did and in what country.
*
Back
Next
General Questions
Why would you like to be a DR intern?
*
Do you speak Spanish fluently? (Not Required)
*
Yes
No
Other
Do you play any musical instruments?
*
Yes
No
Other
Are you involved in any of the following? (Choose as many as apply)
*
Choir
Praise Team
Musical Group
Band
None of the above
Do you play any competitive sports? If yes which ones?
*
Briefly explain your salvation experience.
*
What dreams, hopes, or goals do you wish to pursue in the next 5-10 years?
*
What do you consider gaining through this internship experience? Express any personal goals you wish to achieve.
*
Are you considering full time missions?
*
Yes
No
Undecided
Other
Have you personally lead someone to the Lord?
*
Yes
No
Other
Do you have any experience in personal discipleship? If yes please explain.
*
In your opinion, what principles of concepts does a person need to understand in order to be saved?
*
Back
Next
In what areas of life do you see the need for further growth?
*
Would others say you work well on a team or collaborative effort?
*
What frustrates you the most when working on a team?
*
When you get stress or agitated with someone, how do you tend to react?
*
What would others say are your strengths/weaknesses?
*
Back
Next
References
List three non-relative references who you know well. (References may be contacted)
Reference #1
*
Reference #2
*
Reference #3
*
Have you informed your pastor or a leader in your church of your desire to participate in this internship?
*
Yes
No
Other
Back
Next
Basic Health Form
Name
*
First Name
Last Name
Ethnic Background
*
Age
*
Gender
*
Height
*
Weight
*
Medical History
Hospitalizations:
*
Serious Injuries:
*
Are you currently taking any medication? If so, what is your condition and treatment?
*
Allergies
Medications, animals, food, pollen, other
*
Are there any conditions for which you take regular treatment? If yes what is your condition and treatment?
*
Diseases
Please list and explain indicating any past complications. Check all that apply and explain in the complications box below.
Please select any that apply:
*
Chicken Pox
Measles
Scarlet Fever
Diphtheria
Mumps
Tuberculosis
Hepatitus
Pneumatic Fever
Typhoid
Malaria
Pneumonia
Whooping Cough
Other
Complications:
*
Back
Next
Health Evaluation
Please select any that apply and then provide explanation below:
*
Asthma
Back Trouble
Bipolar
Blackouts
Convulsions
Cough ramps
Cramps
Depression
Diarrhea
Dizziness
Fainting
Hearing
Heartburn
Heart Condition
Joints
Menstrual
Nervousness
Obsessive Compulsive
Severe Headaches
Skin
Sore Throat
Ulcers
Urinary
Vision
Other
Explanation:
*
Have you had any life threatening Diseases? If yes, please explain
*
Do you have any reactions to medications or serum? If yes, please explain.
*
Are you currently on any medication? If yes, please explain.
*
Do you have any special dietary needs? If yes, please explain.
*
Do you have any physical limitations? If yes, please explain.
*
By signing this form you are stating, " I have thoroughly read, understood, and answered all of these questions truthfully and to the best of my ability."
*
Today's Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: