Short-term Outreach Application (Individuals)

Full Name (as appears on passport):
Nickname / Preferred Name (optional):
Gender: --select --- male female
Date of Birth: --Day-- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 --Month-- Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec --Year-- 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Trip Applying for:

Beginning Date:
Until Date:
Current Address:
Permanent Address:
(leave blank if same as current address)
Phone (indicate if home, cell, work):
Additional phone (optional):
E-Mail:
Parents - - -
Full Name:
Phone:
Additional phone:
Full Name:
Phone:
Additional phone:

Birthplace:
Citizenship:
Passport #:
Expiration date:
Issuing location:

Please upload a recent photo of yourself:
Height :
Weight:
Marital Status : --select --- Single Engaged Married Separated Divorced Widowed
Until or Since Date:
Children accompanying you - - -
Name:
Birth Date:
Gender: --select --- male female
Name:

Name:
Birth Date:
Gender: --select --- male female
Name:

Name:
Birth Date:
Gender: --select --- male female
Name:

Name:
Birth Date:
Gender: --select --- male female
Name:

Name of Home Church:
Denomination:
Address:
Phone:
Website(optional):
Pastor's Name:
How long have you attended there?:

In Case of Emergency Contact - - -
First&Last Name:
Relationship to you: --select --- parent spouse friend sibling relative neighbor co-worker other
Phone (indicate if home, cell, work):

Additional phone (optional):
Address:
Health insurance company:
Policy number:

Background - - -
Are you currently a student?: --select --- Yes No
If so, what year?:
How long have you been a Christian?:

Have you ever been involved in a YWAM missions trip or training program?
(Please list date, location, YWAM base, and program leader for each YWAM function you've been involved in.)

Health Information - - -
How would you rate your health condition? --select --- Excellent Good Fair Poor
Known allergies:
Are you now under a doctor’s care for any condition?
(If yes, specify).
Are you taking medication at this time?
(If yes, specify).
Do you have a history of emotional instability or psychiatric treatment?
(If yes, specify).
Would you be able to walk 3-4 miles per day?:
Blood type:

Supplemental Questions - - -
Please prayerfully and concisely answer the following questions.
Describe your conversion experience and present relationship with the Lord.
Have you had any missions experience?
If so, where and what type(s) of ministry did you do?
Why do you desire to serve on this mission trip?
Describe your personal gifts/strengths that you feel would be of service to the team.
What is your greatest struggle/challenge/hindrance in your walk with the Lord?
Have you ever been involved in:
a felonious crime (if so, specify where and when)
a sexual crime (if so, specify where and when)
drug or alcohol abuse
occultism
homosexual practices
Comments:

Do you ever use tobacco or alcohol products in any form?
If so, please explain.
How did you hear about YWAM Louisville?
Please list any special circumstances or situations that we should know about
Any additional comments:
AGREEMENT - - -
I certify that all information in the application is complete and accurate. If accepted by Youth With A Mission, I will abide by the spirit, rules, and schedule of the program. I understand that any documents, including evaluations, refrences and forms in my application or file are YWAM property, and I relinquish the right to view them or obtain information form them in any way. In accordance with biblical principles, I agree to resolve any and all disputes with Youth With A Mission, its board of directors, director, staff or volunteers by means of reconciliation or mediation and waive any right to pursue action by way of litigation. I confirm that I understand that payment of required fees must be made upon or before arrival. I also confirm that I am fully aware of my financial obligation, both to the Lord and to the interns and staff at Youth With A Mission. I therefore commit myself to paying all personal expenses incurred during my involvement with Youth With A Mission.
Please type your full name to certify your agreement.