Disciples' Mentors 25/26 Application Form
DISCIPLES is an Exodus programme that helps those in year 11+ follow Jesus. It offers fun, challenge and support from September to March and includes monthly gatherings, pods (with a mentor and peers) and a residential. A MENTOR is responsible for: helping their pod members grow in faith, helping recruit young people and inputting as needed into monthly gatherings. A MENTOR should be: A committed follower of Christ who will set an example in words, actions, love, faith & purity. They should be passionate about young people developing their relationship with God an committed to upholding the ethos of Exodus.
Personal Details
Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Disciples must be in Year 11+
Address
*
Street Address
Street Address Line 2
City
County
Post Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
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The DISCIPLES Programme
In Which Area Would you Like to be a Mentor for DISCIPLES?
*
Please Select
North East
North West (Derry)
North West (Donegal)
MidUlster
East Antrim/Carrick
Lisburn
Belfast
Banbridge
Previous Involvement with Exodus?
*
Describe your key experience of ministry or leadership
*
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Engagement
Name of Your Church
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Allergies, Dietary Requirements & Medical
Do you have any allergies?
*
Yes
No
If You Answered Yes - please indicate how severe your allergy is
*
Mild
Medium
Severe
Please list below the allergies you have, and if any, recommended actions to take
*
Do you have any medical conditions?
*
Yes
No
Please list any medical conditions, either mild or serious; and list any medication you are taking that Exodus leaders should be aware of.
*
What Advice would you give Exodus leaders to help support you with your condition?
*
Have You Been Issued with an Epipen?
*
Yes
No
Please List Any Dietary Requirements below
*
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Next of Kin
In case of Emergency
Name of Next of Kin
*
First Name
Last Name
What is this Persons Relationship to You?
*
Next of Kin Mobile Number
*
Please enter a valid phone number.
Next of Kin Address
*
Street Address
Street Address Line 2
City
County
Post Code
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Referees
The names and contact details of two people we may ask for a reference. They should not be family members or Exodus staff members.
Referee One Name
*
First Name
Last Name
What is this Persons Relationship to You?
*
Referee One Address
*
Street Address
Street Address Line 2
City
County
Post Code
Referee One Phone Number
*
Please enter a valid phone number. This MUST NOT be your own mobile number.
Referee One Email Address
*
Referee Two Name
*
First Name
Last Name
What is this Persons Relationship to You?
*
Referee Two Address
*
Street Address
Street Address Line 2
City
County
Post Code
Referee Two Phone Number
*
Please enter a valid phone number. This MUST NOT be your own mobile number.
Referee Two Email Address
*
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Legal & Permissions
Have you ever been convicted of a criminal offence?
*
Yes
No
Are you at present the subject of criminal charges?
*
Yes
No
Is there any reason that you could be deemed unsuitable to work with children?
*
Yes
No
Please Tick One Below
*
I give permission for Exodus to use photos/videos of me on social media or for other promotional purposes.
I DO NOT give permission for Exodus to use photos/videos of me on social media or for other promotional purposes.
Please Tick One Below
*
I give permission for Exodus to contact me for about other opportunities in the future
I DO NOT give permission for Exodus to contact me for about other opportunities in the future
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