Internship Application

Medical Information
Gender*

MaleFemale
Do you have any medical conditions, physical limitations, disabilities, etc.?*

YesNo
If yes, please explain
List any allergies (food, medicine, etc.)
List any current medications
Do you regularly use any of the following?*

Narcotic DrugsTobaccoAlcoholic BeveragesNone
Primary Health Insurance Carrier*
Policy Number*
In case of emergency, Primary Contact:*

First NameLast NsameRelationship
Phone Number*
Secondary emergency contact:*

First NameLast NsameRelationship
Phone Number*

Ministry Information
How did you heart about this internship?*
Why do you want to be involved with this particular program?*
Please list any overseas or cross-cultural experiences you have had
Please list any experience working with children or youth
What is your local church affiliation?*
Pastors Name*
Church Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
At what age did you trust Jesus Christ as your personal Lord and Savior?*
Have you been baptised?*

YesNo
Please share how you came to know Christ personally*
What is your approach to spending time alone with Christ?*
Please explain a difficult experience you have faced, and how knowing Christ impacted that experience.*
What are your top three prayer requests concerning your involvement with this mission trip?
1.*
2.*
3.*
Are you willing to be a representative of Jesus Christ and Livada Orphan Care during your time overseas?*

YesNo
Are you willing to submit to the authority of the Livada Orphan Care staff, with whom you will be working, while overseas?*

YesNo
Due to the nature of this minstry, and for the protection of the children we serve, are you willing to sumit to a background check?*

YesNo
Please have three individuals (a ministry leader/diretor whom you have served under, a parent and other adult of your choosing) complete the Reference Questionnaire. These will be emailed to you once the application is recieved to the email provided. Upon completion, your references can email or mail it to the the contact information provided on the form.
Application Agreement

I affirm that all the information provided in this application is true, complete and accurate, to the best of my knowledge. I also agree that any falsified information or significant omission may disqualify me from further consideration for internship and may be considered justification for dismissal if discovered at a later date.

I understand that all funds obtained for this trip are considered charitable contributions to Livada Orphan Care, a 501(c)(3) non-profit organization, and therefore, the property of Livada Orphan Care for frederal income tax purposes and therefore are non-refundable.

I understand and agree to pay the outstanding balance on my account before departing for Romania. I understand if I am not able to meet the deadlines set by Livada Orphan Care, I may be subject to an increase in teh overall cost of my trip. I understand that all payments are to be made out to Livada Orphan Care and sent to Livada's US office.

I understand and agree taht if for any reason I have to withdrawal from the Internship Program prior to my departure, or during the actual internship, I will pay Livada Orphan Care the costs incurred and projected on my behalf, and Livada Orphan Care will provide a documentaed record of such costs. I agree that any monies submitted to Livada Orphan Care, after I have withdrawn, will be used to further its ministry.
Electronic Signature*
Expiration Date*

MonthDayYear
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