Rahab s Rope Application Instructions:

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Rahab s Rope Application Instructions:"

Transcription

1 We are so excited to have you join our work in India. The first step in the process for any volunteer is to fill out the following application in full. Rahab s Rope Application Instructions: Complete the following application and mail or your completed application to Rahab s Rope. If submitting by , send to: If submitting by standard mail, send to: Rahab's Rope P.O. Box Gainesville, Ga If you have questions or need additional information regarding the application process contact: Jillian Hensley Director of Recruiting and Mobilization P.O. Box Bradford Street SE Gainesville, Georgia

2 Rahab s Rope Love in Action India Ministry Application Long-Term Team Member Application Application Date: Position Applying For: Dates Available: Desired Length of Stay (6 mo, 1 yr, etc.): Personal Information Name: Last First Middle Street Address: City: State: Zip Code: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Gender: ( ) Male ( ) Female Date of Birth: Marital Status: (circle one) Single Engaged Married Widowed Separated Divorced If Married, Spouse s Name: If you have children, how many? Do you regularly attend church or a small group disciple-making study group? ( ) Yes ( ) No Please give info of church and or small group leader and how long you have attended: How did you learn of Rahab s Rope?

3 References Spiritual Reference: List a church leader or pastor who knows you and could best serve as a reference. Name: Phone number: Occupation or Relation to you: Years Known: Personal/Employer Reference: Name: Phone number: Relation to you: Years Known: Passport Information Do you have a passport? ( ) Yes ( ) No ( ) Applying Name (as it appears on your passport): Passport Number/Issue Date: Nationality/Place of Issue: Passport Expiration Date: Travel Insurance Information Rahab s Rope will purchase traveler s insurance on your behalf. Please list your beneficiary for this purpose below. Name Relationship

4 IF YOU HAVE BEEN ON A SHORT-TERM TRIP WITH Rahab s Rope YOU ONLY NEED TO ANSWER THE QUESTIONS MARKED WITH AN *. Please answer to the best of your ability the following questions. Feel free to use another sheet of paper. Personal Background Please share your story of salvation in Jesus Christ with 200 words or less. Describe two or three defining moments in your spiritual journey and explain their significance. What do you believe is the biblical purpose/goal of global missions? *Tell us more about your talents, work experiences, skills, and/or foreign languages that may be helpful for the position. Please indicate your level of proficiency: working knowledge, fluent, etc. Ministry Experience List ministries that you have been involved in, both past and present. Include length of involvement. List any cross-cultural and global missions experiences you have had (beginning with the most recent). Indicate the length of each, the country, and the ministry name or organization. Also indicate if you have ever held a leadership position. List any other international travel experience This Position * Please describe why you feel lead to volunteer through Rahab s Rope? A complete application packet includes the following: This application Answers to the above questions regarding personal background, ministry experience, and this position Medical Release Form and Disclaimer (below) Volunteer Agreement (below) A color copy of the endorsement page of your passport (the one with your photo, expiration date and signature). This may be submitted upon receipt of your passport if you are in the process of applying for one.

5 Disclaimer Please initial in the space provided as an indication of understanding and agreement of the statements. Rahab s Rope will not be responsible for extra trip expense (i.e., any transportation or hotel fare changes). Should these occur, they will be passed along to the traveler. I will agree to return home at my own expense if the Rahab s Rope staff determines my behavior is/has been inappropriate and therefore is jeopardizing the short and/or long-term ministry. I understand that my involvement can be denied prior to travel in the event that I do not participate in the full preparation of the position (i.e., Training). In submitting this application: I am expressing my agreement with Rahab s Rope s Vision, Mission, Goal, Values, and Strategy I am willing to work under the direction of Rahab s Rope, the Team Leader, and Field Partners to accept and to perform any and all assignments with a God-honoring attitude. I am willing to conform to the standards of the national Christians, even if those standards are stricter than my own. I agree to be subject to a background check. I am confirming that I have the time and energy to devote to the position, including preparation prior to departure, and follow-up after returning I have read and agree to the below deposit and payment information. Signature / Date Registration Registration is complete for a participant only once application has been approved and $150 deposit has been submitted to Rahab s Rope. Registration can be initiated by turning in the application but will not be complete until applicant has been accepted and deposit has been received. Support-Raising Schedule All payments for Rahab s Rope Mission Trips should be made payable to Rahab s Rope. $150 non-refundable, non-transferable deposit to be made within two weeks of acceptance. $2000 due 60 days prior to departure 75% of total support due at time of departure, with additional 25% committed through pledges Note: No refunds can be given for excess funds donated as they are specifically donated to Rahab s Rope. Excess funds will be used for designated ministry.

6 Rahab s Rope Medical Release / Permission to Treat Form Team Information (if known) Team Leader: Trip Location: Trip Dates: Personal Information Full Name: Gender: SSN: DOB: Age: Address: City: State: Zip Code Home Phone: Cell Phone: Parent/Guardian (if younger than 19 years old): Emergency Contact Information Please provide the name and contact information of two individuals not traveling with your team who may be contacted in the event of an emergency. Name: Relationship to You: Phone: Alt. Phone: Name: Relationship to You: Phone: Alt. Phone: Insurance Information Please attach a copy of the front and back of your insurance card. Insurance Company: Policy Holder: Relationship: Policy #: Group #: Ins. Co. Address: Phone: Medical Information Primary Care Physician: Physician Address: Phone: Do you have any allergies? yes no If yes, please explain: List any specific medical conditions requiring medical treatment and/or medication:

7 List ALL medication taken on a regular basis: List all operations/serious injuries (include dates) within the past five years: Have you had contact with contagious or infectious diseases within the last four weeks? yes no If yes, please explain: Do you have any special dietary restrictions? yes no If yes, please explain: What type of pain medication may be given if necessary? Emergency Authorization I hereby give permission to medical personnel selected by my team leader or his/her designee (hereafter the Authorized Agent) to order X-rays, routine tests, and treatment for me. In the event of an emergency and neither my primary nor secondary contact can be reached, I hereby give permission to the physician selected by the Authorized Agent to secure proper treatment, hospitalize, order injections and/or anesthesia, and/or authorize surgery for me. I further authorize the release of the above medical information to appropriate medical personnel and/or the health coverage insurance company. In addition, I have, and do hereby, release Rahab s Rope, its employees or agents, and in country contacts from liability associated with participation in a mission trip. I understand that if I do not have medical insurance, I will be responsible for any medical expenses in the event of a sickness or injury. I understand that there are risks involved in participating in a mission trip. Signature: Date: (Must be signed by a parent or guardian if under 19 years of age.)

8 Volunteer Agreement Please read the following policies, and sign the document to demonstrate your agreement to abide by them during your time with Rahab s Rope. Alcohol consumption of any kind or use of tobacco products is unacceptable during your time in India. Culturally it is perceived as highly inappropriate for a Christian to consume alcohol or smoke. No drugs (outside of medical purposes) are permitted. Never go anywhere alone. Always travel with at least one other person. Tattoos and piercings may not be acquired during your time in India. For those with existing tattoos/piercings, on rare occasions tattoos may need to be covered, and piercings removed in order to be considered appropriate. Your field contact will make you aware of these times. Starting a dating or physical relationship of any kind is forbidden during your time as a volunteer with Rahab s Rope. This includes other volunteers, locals, and anyone else you might meet during your time in India. It is distracting to the ministry, and can result in a volunteer being immediately sent back to the U.S. All volunteers must be willing to comply with the standards of appropriate behavior for local Christians, even if those standards are stricter then the volunteer s own. I have read the above policies, and agree to them in full. Should I breach any of these policies I understand I will be sent home at my own expense. Signature Date

Calvary Chapel Bible College Nepal G.P.O. Box: 8975 E.P.C: 1563 Kathmandu, Nepal ccbcnepal@gmail.com www.ccbcnepal.com

Calvary Chapel Bible College Nepal G.P.O. Box: 8975 E.P.C: 1563 Kathmandu, Nepal ccbcnepal@gmail.com www.ccbcnepal.com Calvary Chapel Bible College Nepal G.P.O. Box: 8975 E.P.C: 1563 Kathmandu, Nepal ccbcnepal@gmail.com www.ccbcnepal.com New Student Application For students that have never enrolled in CCBC classes. Basic

More information

Faculty Group Practice Patient Demographic Form

Faculty Group Practice Patient Demographic Form Name (Last, First, MI) Faculty Group Practice Patient Demographic Form Today s Patient Information Street Address City State Zip Home Phone SSN of Birth Gender Male Female Work Phone Cell Phone Marital

More information

STEPS TO ADMISSION We recommend that interested parents schedule a campus tour.

STEPS TO ADMISSION We recommend that interested parents schedule a campus tour. So the generations to come might know Him Psalm 78:4 STEPS TO ADMISSION We recommend that interested parents schedule a campus tour. Application Process 1. Complete and return the application with the

More information

New Student Application Packet

New Student Application Packet New Student Application Packet This application is for NEW Students (those who have never attended a CCBC campus). If you have attended CCBC Murrieta or any other CCBC extension campus, please only complete

More information

Winter Camp 2015 Church Registration Instructions and Policies

Winter Camp 2015 Church Registration Instructions and Policies Winter Camp 2015 Church Registration Instructions and Policies Registration Instructions: 1) Choose your weekend(s). Prayerfully consider which available weekend is the best for your church. Bring your

More information

Patient Information: In Case of Emergency: Physician: Insurance:

Patient Information: In Case of Emergency: Physician: Insurance: For office use only: Start of Care: ICD-9 Codes: Patient Information: Name: Address: City: State: IL Zip: Patient of Birth: Policy Holders of Birth: of Injury or Onset of Symptoms: Home Phone: Work Phone:

More information

2015 Nature Explorers Registration Form (Rising 1st to 3rd graders)

2015 Nature Explorers Registration Form (Rising 1st to 3rd graders) Information 2015 Nature Explorers Registration Form (Rising 1st to 3rd graders) Camper Name: DOB: Parent/Guardian Name(s): Address: City: State: Zip: Home Cell Work Email: *If emergency contact is different

More information

Patient History Information

Patient History Information Date: Body Technic Systems, Inc. 33790 Bainbridge Rd. Ste. 205 Solon, Ohio 44139 440-248-9255 phone 440-248-3608 fax Patient History Information Name: Date of birth: Address: City: State: Zip: Home phone:

More information

Faculty Group Practice Patient Demographic Form

Faculty Group Practice Patient Demographic Form Name (Last, First, MI) Faculty Group Practice Patient Demographic Form Today s Date Patient Information Street Address City State Zip Home Phone Work Phone Cell Phone ( ) Preferred ( ) Preferred ( ) Preferred

More information

APPLICATION FOR ADMISSION

APPLICATION FOR ADMISSION APPLICATION FOR ADMISSION BIOGRAPHICAL INFORMATION (Please type or print clearly) Full name (Last) (First) (Middle) Date of birth (DD-MM-YYYY) Place of birth (city, country) Sex Citizenship Do you possess

More information

Midha Medical Clinic REGISTRATION FORM

Midha Medical Clinic REGISTRATION FORM Midha Medical Clinic REGISTRATION FORM Today s / / (PLEASE PRINT NEATLY) PATIENT INFORMATION Last Name: First Name: Middle Initial: IS THIS YOUR LEGAL NAME? YES NO IF NOT, WHAT IS YOUR LEGAL NAME DATE

More information

On the last page of the application, please remember to circle which session you are applying for.

On the last page of the application, please remember to circle which session you are applying for. ATLANTA SCHOOL OF MINISTRY ATLANTA SCHOOL OF MINISTRY Letting Heaven Invade Earth Letting Heaven Invade Earth Dear Atlanta SOM Applicant, We are excited that you have taken the time to apply to the Atlanta

More information

Youth Ministry Volunteer Staff: Application Background Check Guidelines

Youth Ministry Volunteer Staff: Application Background Check Guidelines S T. M ARK S LU THERAN C H U RCH Youth Ministry Volunteer Staff: Application Background Check Guidelines This application is to be completed by all Youth Ministry staff and volunteers. It is part of our

More information

SEMINARY APPLICATION FORMS 20141003

SEMINARY APPLICATION FORMS 20141003 SEMINARY APPLICATION FORMS 20141003 Checklist All of the following documents must be received by CSBS before an application will be reviewed for admission. Please use the following checklists as a guide:

More information

Return completed documents to your faculty member by the deadline provided

Return completed documents to your faculty member by the deadline provided Student Checklist Student Conditions of Participation Agreement and Release Insurance Registration Form (Office of International Programs will provide information necessary to contact insurance company.

More information

Short-Term Missions Trip Application

Short-Term Missions Trip Application 545 Hillsdale Avenue, San Jose, CA 95136 (408) 269-4782 or (408) 269-7204 - fax Short-Term Missions Trip Application Application Guidelines: 1. To begin the process, please contact Sarah Hale, Short-Term

More information

Important Information Please keep this page for your records

Important Information Please keep this page for your records Camp Horizon Important Information Please keep this page for your records 1. Complete the enclosed application and the scholarship form thoroughly. Mail them immediately to the camp address listed below.

More information

Blessings to you from Charis Bible College,

Blessings to you from Charis Bible College, Blessings to you from Charis Bible College, Thank you for your interest in our school. We are pleased that your desire is to study the Word and the good news of the gospel with us. The first step in the

More information

Mode of Study (Tick ): Regular [ ] Evening [ ] School Based [ ]

Mode of Study (Tick ): Regular [ ] Evening [ ] School Based [ ] SCOTT CHRISTIAN UNIVERSITY P.O BOX 49-90100; Phone: +254 713 745 404/ +254 734 833 832 MACHAKOS, KENYA APPLICATION FOR ADMISSION IMPORTANT: Before filling out this Application Form, please read carefully

More information

Wayne Physical Medicine & Rehabilitation Associates 401 Hamburg Turnpike, Suite 105 Wayne, NJ 07470

Wayne Physical Medicine & Rehabilitation Associates 401 Hamburg Turnpike, Suite 105 Wayne, NJ 07470 PLEASE FILL OUT THIS SHEET COMPLETELY AND CORRECTLY. PLEASE PROVIDE ALL INSURANCE CARDS TO THE RECEPTIONIST TO COPY. Name Social Security # Address City, State & Zip Code Home Phone No. ( ) Cell Phone

More information

Name Grade DOB Male/Female. Nickname School: Primary Address: Secondary Address: Youth . Youth Home Phone Youth Cell Phone.

Name Grade DOB Male/Female. Nickname School: Primary Address: Secondary Address: Youth  . Youth Home Phone Youth Cell Phone. Christ Church Youth Ministry 2012-2013 Universal Permission Form Effective Dates: September 1, 2012 August 31, 2013 YOUTH INFORMATION Name Grade DOB Male/Female Nickname School: Primary Address: Secondary

More information

Please complete the Mission Trip Application in it s entirely before submitting.

Please complete the Mission Trip Application in it s entirely before submitting. Mission Trip Application & Financial Information * This application is for those who would like to participate in a short-term mission trip with Gospel Community Church. Please complete the Mission Trip

More information

Calvary Chapel Bible College Indianapolis Campus 7702 Indian Lake Road Indianapolis, IN. 46236 (317) 823-2349 / info@ccbci.org

Calvary Chapel Bible College Indianapolis Campus 7702 Indian Lake Road Indianapolis, IN. 46236 (317) 823-2349 / info@ccbci.org Calvary Chapel Bible College Indianapolis Campus 7702 Indian Lake Road Indianapolis, IN. 46236 (317) 823-2349 / info@ccbci.org Are you after the heart of God? Do you desire to grow in the grace and knowledge

More information

Physical Occupational and Speech Therapy Patient Information Sheet

Physical Occupational and Speech Therapy Patient Information Sheet Physical Occupational and Speech Therapy Patient Information Sheet FIRST NAME: MI: LAST NAME: ADDRESS: HOME PHONE: WORK PHONE: MALE FEMALE CELLPHONE: DOB: SS# EMERGENCY CONTACT: PHONE: RELATIONSHIP: PRIMARY

More information

Salt Creek Baptist Church. Associate Pastor of Youth Ministries Pastor Application Packet

Salt Creek Baptist Church. Associate Pastor of Youth Ministries Pastor Application Packet Salt Creek Baptist Church Associate Pastor of Youth Ministries Pastor Application Packet 2 Dear Applicant, Thank you for you interest in our opening. The Associate Pastor of Youth Ministries is an integral

More information

AFRICA INTERNATIONAL CHRISTIAN MISSION, INC. Short-Term Mission Application Form APPLICATIONS WILL NOT BE ACCEPTED WITHOUT A PHOTO AND DEPOSIT!

AFRICA INTERNATIONAL CHRISTIAN MISSION, INC. Short-Term Mission Application Form APPLICATIONS WILL NOT BE ACCEPTED WITHOUT A PHOTO AND DEPOSIT! AFRICA INTERNATIONAL CHRISTIAN MISSION, INC. Short-Term Mission Application Form INSTRUCTIONS: 1. Complete the Application Form. 2. Attach a recent photo to the application form along with a photo-quality

More information

Christ s Grace compels us to RISK ALL, LOVE ALL to make His name great.

Christ s Grace compels us to RISK ALL, LOVE ALL to make His name great. Prospective Youth Leader Letter MDPC Youth Ministry Volunteer Application Driver s Application Volunteer Adult Youth Leader Release Form Copy of Driver s License Copy of Car Insurance Copy of Medical Insurance

More information

REGISTRATION FORMS. Child s Full Name: Birth Date: / / Boy Girl. Child s Full Name: Birth Date: / / Boy Girl

REGISTRATION FORMS. Child s Full Name: Birth Date: / / Boy Girl. Child s Full Name: Birth Date: / / Boy Girl REGISTRATION FORMS Child s Full Name: Birth Date: / / Boy Girl Child s Full Name: Birth Date: / / Boy Girl Child s Full Name: Birth Date: / / Boy Girl Address: City: State: Zip Code: Child #1 Days of the

More information

Hope of the Nations Bible College In His name the nations will put their hope. Matthew 12:21

Hope of the Nations Bible College In His name the nations will put their hope. Matthew 12:21 In His name the nations will put their hope. Mt. 12:21 Hope of the Nations Bible College In His name the nations will put their hope. Matthew 12:21 P.O. Box 841 Kigoma, Tanzania, East Africa Short-Term

More information

Application for Admission 2016 Disciples Days July 9-16, 2016

Application for Admission 2016 Disciples Days July 9-16, 2016 Application for Admission 2016 Disciples Days July 9-16, 2016 Disciples Days is seeking mature Christian youth who have: A passion for God, spiritual growth, and A capacity to interact effectively with

More information

Admission Forms. Texas Bible College 3900 College Drive Lufkin, Texas 75901. Office (936) 633-7799 Fax (936) 699-2600

Admission Forms. Texas Bible College 3900 College Drive Lufkin, Texas 75901. Office (936) 633-7799 Fax (936) 699-2600 Admission Forms Texas Bible College 3900 College Drive Lufkin, Texas 75901 Office (936) 633-7799 Fax (936) 699-2600 Steps for Admission: Step 1: Complete the Application for Admission. Step 2: Mail the

More information

Applying for Admission. 2. Mail the application to the college along with a $20 application fee which is non-refundable.

Applying for Admission. 2. Mail the application to the college along with a $20 application fee which is non-refundable. Application Packet First-Time Students 1. Complete the application and attach a recent photo. Applying for Admission 2. Mail the application to the college along with a $20 application fee which is non-refundable.

More information

Please write clearly, or type. All blanks must be completed for this application to be processed.

Please write clearly, or type. All blanks must be completed for this application to be processed. LEVEL 1 STUDENT APPLICATION FORM Please write clearly, or type. All blanks must be completed for this application to be processed. Please be sure the following is included: An application is not processed

More information

Your appointment is scheduled for:

Your appointment is scheduled for: 14090 H.G. Trueman Road, Suite 1400 Solomons, MD 20688 410-610- 2246 Rebecca L Jahed, AuD, FAAA Welcome to Freedom Hearing Center. My name is Dr. Rebecca L. Jahed and I am the President of this private

More information

OASIS CHURCH MISSIONS TRIP APPLICATION

OASIS CHURCH MISSIONS TRIP APPLICATION OASIS CHURCH MISSIONS TRIP APPLICATION NOTE: The initial deposit is non refundable and due with the application. This deposit typically covers airfare and enables us to not jeopardize our group rate if

More information

AYC Mission 2016 Ireland/Poland July 5-15

AYC Mission 2016 Ireland/Poland July 5-15 AYC Mission 2016 Ireland/Poland July 5-15 We are excited to announce our AYC mission to Ireland and Krakow, Poland 2016. We will be spending time with our ALJC Missionaries in Ireland and in Poland. We

More information

MINISTRY SCHOOL APPLICATION FORM

MINISTRY SCHOOL APPLICATION FORM MINISTRY SCHL APPLICATIN FRM INFRMATIN First Name: Last Name: Birth Date: Email Address: Phone Number: Address: City, State, Zip: PERSNAL Gender: Male Female Marital Status: Single Married Divorced Widowed

More information

Application Packet CDI. Camp David Internship CHICAGO HOUSE OF PRAYER

Application Packet CDI. Camp David Internship CHICAGO HOUSE OF PRAYER Application Packet CDI Camp David Internship CHICAGO HOUSE OF PRAYER CDI Appli c a t i o n Pr o c e s s 1. The application has five components. We ask that you submit all five components together in one

More information

AMPED YOUTH MINISTRY Program Form

AMPED YOUTH MINISTRY Program Form AMPED YOUTH MINISTRY Program Form Youth participant s full name: Date of Birth: Sex: Male Female Address: Home Phone: Cell Phone: Email: School: Grade: May the youth ministry leaders/ volunteers contact

More information

GUATEMALA SURGERY TRIP Youth Volunteer Information and Release Form

GUATEMALA SURGERY TRIP Youth Volunteer Information and Release Form Team Name: Guatemala Surgery Travel Dates GUATEMALA SURGERY TRIP Youth Volunteer Information and Release Form Please complete this entire form, including the release and liability form and return immediately.

More information

APPLICATION FOR UNDERGRADUATE STUDIES

APPLICATION FOR UNDERGRADUATE STUDIES APPLICATION FOR UNDERGRADUATE STUDIES Application for Admission undergraduate INDIANA BAPTIST COLLEGE 1301 W. County Line Road, Greenwood, IN 46142 New Student Admissions Information:317-882-2345 Website:

More information

PATIENT REGISTRATION FORM PATIENT INFORMATION

PATIENT REGISTRATION FORM PATIENT INFORMATION Siepser Laser Eye Care PATIENT REGISTRATION FORM : PATIENT INFORMATION First Name Middle Initial: Last Name: Birth : Gender: Male Female Marital Status: SSN: Driver s License #: Address: City: State: Zip:

More information

Mizoram Bible College

Mizoram Bible College APPLICATION FORM (Every question must be answered) The course applied for: Affix your recent passport (1) B.Th [ ] (2) Dip.Th [ ] (3) C.Th [ ] size photograph I. PERSONAL DETAILS 1. Name in Full (Use Block

More information

Admission Process Checklist

Admission Process Checklist Admission Process Checklist Send these five items to Apostolic School of Theology: 1. A completed graduate application for admission. 2. An application fee in the form of a check, credit card, or money

More information

Application Procedure FIRE School of Ministry

Application Procedure FIRE School of Ministry Application Procedure PLEASE READ THIS DOCUMENT IN ITS ENTIRETY BEFORE APPLYING WHEN TO APPLY: accepts students twice per year, at the start of the Fall and Spring semesters. Prospective students should

More information

Application for admission

Application for admission Office of Admissions - 7200 S. Hampton Road - Dallas, TX 75232-972.224.5481 Application for admission Thank you for your interest in Southern Bible Institute! Southern Bible Institute is a non-denominational

More information

PATIENT REGISTRATION Date:

PATIENT REGISTRATION Date: PATIENT REGISTRATION Date: PLEASE PRESENT YOUR DRIVER S LICENSE AND INSURANCE CARDS TO RECEPTION DESK. INSURANCE CO-PAYMENTS ARE EXPECTED BEFORE SERVICES ARE RENDERED. PAYMENT IN FULL IS EXPECTED WHEN

More information

VOLUTEER LEADERS SAINT CHRISTOPHER JOURNEYS, LLC LIMITATION OF LIABILITY STATEMENT

VOLUTEER LEADERS SAINT CHRISTOPHER JOURNEYS, LLC LIMITATION OF LIABILITY STATEMENT VOLUTEER LEADERS Saint Christopher Journeys LLC uses the services of volunteer leaders for the journeys. Volunteer leaders do not pay for their participation in the journey. In the case of international

More information

TUITION RATES SCHOOL YEAR 2015-2016

TUITION RATES SCHOOL YEAR 2015-2016 TUITION RATES SCHOOL YEAR 2015-2016 REGISTRATION FEE: $65.00 per child DISCOUNTS: Family discount apply to families with two or more children in the Extended Day program. Full price is paid for the youngest

More information

LIVING WATERS THEOLOGICAL SEMINARY Tynwald Campus

LIVING WATERS THEOLOGICAL SEMINARY Tynwald Campus LIVING WATERS THEOLOGICAL SEMINARY Tynwald Campus P.O.BOX M100 Mabelreign Harare Tel: 04-2906191 E-mail:info@lwtszim.org STUDENT APPLICATION FORM 1. Complete all the required items 2. Print in BLOCK LETTERS

More information

Nephrology Consultants of Georgia, P.C.

Nephrology Consultants of Georgia, P.C. New Patient O (Check One) Established Patient O Name: (Last) _ (First) (MI) Address: City State Zip D.O.B. SSNO Email Address Ethnicity: O Hispanic or Latino O Not Hispanic or Latino O Patient Refused

More information

Application for Admission

Application for Admission Application for Admission Application Checklist All applicants must submit the following to complete the application process: $35 Application Fee Photograph Pastoral Recommendation Personal Recommendation

More information

2015 PCM Spring Break Mission Trip Silver City, New Mexico

2015 PCM Spring Break Mission Trip Silver City, New Mexico 2015 PCM Spring Break Mission Trip Silver City, New Mexico DATES: March 14-18, 2015 DESCRIPTION: We will be traveling to the historic small town of Silver City, New Mexico and partnering with First Presbyterian

More information

South Florida Bible College & Theological Seminary 747 S. Federal Highway Deerfield Beach, FL 33441 954-426-8652 toll-free 1-800-432-1926 www.sfbc.

South Florida Bible College & Theological Seminary 747 S. Federal Highway Deerfield Beach, FL 33441 954-426-8652 toll-free 1-800-432-1926 www.sfbc. Page 1 of 8 South Florida Bible College & Theological Seminary 747 S. Federal Highway Deerfield Beach, FL 33441 954-426-8652 toll-free 1-800-432-1926 www.sfbc.edu Expected Entry and Status Application

More information

P.S. Please remember to bring your completed forms to your office visit!

P.S. Please remember to bring your completed forms to your office visit! Dear Patient: Please print the following forms and complete them as accurately as possible and bring them with you to your office visit. If you have any questions about the forms you can call my office

More information

Orthodontics on Silver Lake, P.A. Stephanie E. Steckel, D.D.S., M.S. Welcome To Our Office -Please Print-

Orthodontics on Silver Lake, P.A. Stephanie E. Steckel, D.D.S., M.S. Welcome To Our Office -Please Print- HEALTH HISTORY Orthodontics on Silver Lake, P.A. Stephanie E. Steckel, D.D.S., M.S. Welcome To Our Office -Please Print- Date: 20 Date of Birth: Patient s name: First Middle Last Name Patient Prefers to

More information

PATIENT REGISTRATION Date:

PATIENT REGISTRATION Date: PATIENT REGISTRATION Date: PLEASE PRESENT YOUR DRIVER S LICENSE AND INSURANCE CARDS TO RECEPTION DESK. INSURANCE CO-PAYMENTS ARE EXPECTED BEFORE SERVICES ARE RENDERED. PAYMENT IN FULL IS EXPECTED WHEN

More information

PISTIS SCHOOL OF MINISTRY 2311 Medical District Drive Dallas, TX 75235 P: 214-559-6121 F: 214-559-6135

PISTIS SCHOOL OF MINISTRY 2311 Medical District Drive Dallas, TX 75235 P: 214-559-6121 F: 214-559-6135 SPOUSAL INFORMATION PISTIS SCHOOL OF MINISTRY 2311 Medical District Drive Dallas, TX 75235 P: 214-559-6121 F: 214-559-6135 Will your spouse or fiancé(e) apply to the School of Ministry (SOM) this September?

More information

Virginia South Psychiatric & Family Services

Virginia South Psychiatric & Family Services All forms must be completed before seeing the Physician Information for Medical Records Patient s Name: Social Security #: Date of Birth: Sex: Male Female Marital Status: Single Married Divorced Widow

More information

Horizon Eye Care, P.A. Patient Information Sheet. For your convenience, please print and complete the pre-registration forms before your visit.

Horizon Eye Care, P.A. Patient Information Sheet. For your convenience, please print and complete the pre-registration forms before your visit. Patient Information Sheet For your convenience, please print and complete the pre-registration forms before your visit. Section 1: Patient's Legal Name: (First, MI, Last) Parent / Guardian: (If applicable)

More information

Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013. Today s Date: How did you hear of our practice?

Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013. Today s Date: How did you hear of our practice? Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas 75013 Name: First Middle Last Today s Date: How did you hear of our practice? Home Address: City: State: Zip: Home Phone:

More information

WELCOME TO YMCA Teen Scene Middle School Enrichment Program (This sheet is for parents to keep for informational purposes)

WELCOME TO YMCA Teen Scene Middle School Enrichment Program (This sheet is for parents to keep for informational purposes) Robert D. Fowler Family YMCA Middle School Enrichment Program Student Registration Form 2015-16 Ivy Prep Academy Program Hours: 7am-7:45am & 4pm-7pm Transportation AM: Group leaves at 7:30am Transportation

More information

Intern Information Packet

Intern Information Packet Intern Information Packet What is the GO TELL Internship Program? The GO TELL Summer Intern program is an awesome opportunity for high school graduates and college students from around the country to participate

More information

Lifeway Information Form

Lifeway Information Form Lifeway Information Form Patient Name: First MI Last Date of Birth: / / Gender: M F Marital Status: M S D Address: City State: Zip: Primary Contact Phone: Secondary Contact Phone: Please circle home cell

More information

juilliard.edu/summerjazz

juilliard.edu/summerjazz Juilliard JAZZ Summer 2013 Camp in Atlanta,GA June 17-21, 2013 One-week program for dedicated and disciplined students ages 12-18, who are passionate about jazz music For details see Juilliard s Web site:

More information

TRAVEL APPLICATION FORM

TRAVEL APPLICATION FORM Page 1 of 5 TRAVEL APPLICATION FORM Full Name (as on passport): Home Address: Birth Date: Passport Number: Citizenship: First M.I. Last street city state zip Birth Place Exp.Date (must be valid for six

More information

THE APPLICATION PROCESS - DEGREE STUDENTS

THE APPLICATION PROCESS - DEGREE STUDENTS THE APPLICATION PROCESS - DEGREE STUDENTS 1. Completely fill out the application. IMPORTANT: Use the Living Word Ministry University application if you desire to work toward your college degree. Use the

More information

Dear Patients and Prospective Patients:

Dear Patients and Prospective Patients: www.cheverlychiropracticcare.com CheverlyChiroCare@yahoo.com Dr. Ella Pantazis 12200 Annapolis Rd #221 GlennDale MD 20769 301 464 5813 Fax: 301 464 5815 Dear Patients and Prospective Patients: Our office

More information

Transitions Counseling Growing Towards Change 8641 5 th Street, Suite W-6 Frisco, Texas 75034 Phone: 972-369-9462 Fax: 972-636-8047

Transitions Counseling Growing Towards Change 8641 5 th Street, Suite W-6 Frisco, Texas 75034 Phone: 972-369-9462 Fax: 972-636-8047 Transitions Counseling Growing Towards Change 8641 5 th Street, Suite W-6 Frisco, Texas 75034 Phone: 972-369-9462 Fax: 972-636-8047 Insurance Information Sheet It is important that you thoroughly complete

More information

CLERGY/MILITARY CHAPLAIN APPLICATION FORM

CLERGY/MILITARY CHAPLAIN APPLICATION FORM CLERGY/MILITARY CHAPLAIN APPLICATION FORM Application for the Warriors to Lourdes Pilgrimage, 17-23 May 2016 Applicants are encouraged to complete this form electronically for better legibility; completed

More information

Thank you for your cooperation.

Thank you for your cooperation. DR. RICHARD P. TOWNSEND M.D. VERONICA DEAN FNP-C Family Nurse Practitioner LAURA GRUNDY FNP-BC Family Nurse Practitioner Dr. Richard Townsend is a third generation physician. He was educated in Canada

More information

Your appointment is scheduled for at with Dr. Your arrival time is.

Your appointment is scheduled for at with Dr. Your arrival time is. Dear : We appreciate your selection of our office for your complete eye care. Your appointment is scheduled for at with Dr. Your arrival time is. First visits usually take approximately one and a half

More information

Teacher Application 113 Oakwood Street, Chickamauga, GA 30707 706-375-7247

Teacher Application 113 Oakwood Street, Chickamauga, GA 30707 706-375-7247 Teacher Application 113 Oakwood Street, Chickamauga, GA 30707 706-375-7247 Position Desired Personal Information Application Date / / Full Name Last First Middle Maiden (if applicable) Physical Address

More information

Next Level Physical Therapy PC Patient Information

Next Level Physical Therapy PC Patient Information Next Level Physical Therapy PC Patient Information First Name M.I. Last Name Date of Birth SS# (if minor, leave blank) Student? F/T P/T NO Street Address Billing Address (if different) City State Zip Home

More information

PATIENT REGISTRATION FORM

PATIENT REGISTRATION FORM 201 N. Park Ave Suite 201 Apopka, FL 32703 Office (407)228-3180 Fax: (407)-228-3725 PATIENT REGISTRATION FORM Last Name: First Name: Middle Initial Male Female Date of Birth: Marital Status: Single Married

More information

Application. An External Biblical Studies Program of Rock of Ages Ministries P.O. Box 4419 Dalton, GA 30719 Phone (706) 459-3233 ROACOBS@gmail.

Application. An External Biblical Studies Program of Rock of Ages Ministries P.O. Box 4419 Dalton, GA 30719 Phone (706) 459-3233 ROACOBS@gmail. Application Rock of Ages College of Biblical Studies and Theological Seminary An External Biblical Studies Program of Rock of Ages Ministries P.O. Box 4419 Dalton, GA 30719 Phone (706) 459-3233 ROACOBS@gmail.com

More information

HIGH MIDDLE SCHOOL SCHOOL MINISTRY. volunteer application

HIGH MIDDLE SCHOOL SCHOOL MINISTRY. volunteer application HIGH SCHOOL MIDDLE SCHOOL MINISTRY volunteer application Are you in? Students have a lot of questions, like who are my friends? How can I get along with my parents? What am I going to do when I grow up?

More information

Youth Leader. Application

Youth Leader. Application Youth Leader Application Adult Youth Leader To assist in the operations of youth services and in providing a consistent weekend service that will capture the youth s attention and challenge them to become

More information

Youth Ministry Registration Form. Please complete this form for all children participating in children s ministry.

Youth Ministry Registration Form. Please complete this form for all children participating in children s ministry. Youth Ministry Registration Form Please complete this form for all children participating in children s ministry. Last Name First Name DOB Male or Female Parent(s)/Guardian(s): Street Address: City: State:

More information

LOUDONVILLE COMMUNITY CHURCH

LOUDONVILLE COMMUNITY CHURCH LOUDONVILLE COMMUNITY CHURCH Instructions for the Short Term Trip Application for Funding and Prayer Thank you for your interest in missions. Please follow the instructions below for submitting an application.

More information

You are scheduled to see Dr. Kennard: at. On the day of your visit, he will be located at: (Directions are enclosed)

You are scheduled to see Dr. Kennard: at. On the day of your visit, he will be located at: (Directions are enclosed) Your dermatologist has referred you for treatment of your skin condition. We would like to take this opportunity to welcome you and give you information that will make your appointment with us go smoothly.

More information

APPLICATION FOR ADMISSION

APPLICATION FOR ADMISSION APPLICATION FOR ADMISSION Thank you for your interest in the Lifepoint Leadership College. If you have any questions, please contact our staff at leadershipcollege@lifepointnow.com. Additional information

More information

When you arrive for your first appointment, please bring the following with you:

When you arrive for your first appointment, please bring the following with you: 115 N. Sumter Street, Suite 400, Sumter, SC 29150 Phone (803) 774-7425 (SICK) / Fax (803) 774-9426 www.cfmsumter.com WELCOME We are honored that you have chosen Carolina Family Medicine of Sumter for your

More information

Patient Demographic Sheet

Patient Demographic Sheet Patient Demographic Sheet Patient Name: Date of Birth: Address: City, State, Zip Code: Home Phone: Cell Phone: Work Phone: E-Mail: Sex: Male Female Marital Status: Married Single Other Occupation: Employer:

More information

APPLICATION FOR ADMISSION WEST AFRICA ADVANCED SCHOOL OF THEOLOGY (WAAST)

APPLICATION FOR ADMISSION WEST AFRICA ADVANCED SCHOOL OF THEOLOGY (WAAST) APPLICATION FOR ADMISSION WEST AFRICA ADVANCED SCHOOL OF THEOLOGY (WAAST) Instructions: Please fill out this form completely, in your own handwriting, and mail to: WAAST, B.P. 2313, Lomé, Togo, or scan

More information

2014 High School Police Academy Application Packet. Session 1: July 7 th 11 th Session 2: August 11 th 15 th

2014 High School Police Academy Application Packet. Session 1: July 7 th 11 th Session 2: August 11 th 15 th 2014 Application Packet Session 1: July 7 th 11 th Session 2: August 11 th 15 th The Charlotte-Mecklenburg Police Department is offering high school students in Mecklenburg County the opportunity to experience

More information

Enclosed you will find an Application form and other forms necessary for enrolment at BBC.

Enclosed you will find an Application form and other forms necessary for enrolment at BBC. Dear Applicant, Thank you so much for your interest in Baptist Bible College. Decisions about Christian training and education are among the most important any person will every make. It is hoped that

More information

LUMP SUM BENEFIT APPLICATION

LUMP SUM BENEFIT APPLICATION NATIONAL ELECTRICAL ANNUITY PLAN NEAP LUMP SUM BENEFIT APPLICATION 2400 Research Boulevard, Suite 500, Rockville, MD 20850-3266 Telephone (301) 556-4300 Rev 01/12 National Electrical Annuity Plan Lump

More information

New Student Registration Forms. Registration Checklist

New Student Registration Forms. Registration Checklist New Student Registration Forms Registration Checklist To be completed only if offered a spot Please print these registration documents All forms should be completed in full The following list includes

More information

MISSIONARY PERSONAL SUPPORT APPLICATION

MISSIONARY PERSONAL SUPPORT APPLICATION MISSIONARY PERSONAL SUPPORT APPLICATION Dear Missionary Personal Support Applicant, Thank you for the work you are doing in your community! We are grateful for individuals like you who are spending their

More information

Oklahoma Baptist College & Institute

Oklahoma Baptist College & Institute 5517 NW 23 rd Street Oklahoma City, OK 73127 (405) 943-3334 office@oklahomabaptistcollege.com Application for Admission Accreditation Status Oklahoma Baptist College and Institute is not accredited under

More information

Gastroenterology Associates, N.A. P.C. Patient Demographic & Insurance Information

Gastroenterology Associates, N.A. P.C. Patient Demographic & Insurance Information Gastroenterology Associates, N.A. P.C. Patient Demographic & Insurance Information Basic Patient Information Patient s Social Security Number: Date: Name of Patient: First Middle Last Birth Date: Age:

More information

UNIVERSITY CHRISTIAN SCHOOL

UNIVERSITY CHRISTIAN SCHOOL UNIVERSITY CHRISTIAN SCHOOL Dear Prospective Parent: Thank you for your interest in University Christian School. For over four decades, University Christian has been committed to providing families an

More information

ETHIOPIA SHORT TERM MISSION TRIP OCTOBER 2014

ETHIOPIA SHORT TERM MISSION TRIP OCTOBER 2014 ETHIOPIA SHORT TERM MISSION TRIP OCTOBER 2014 Completion of this application does not necessarily guarantee a place on the mission trip. Each application will be reviewed by the Missions Director and/or

More information

Livingstone 4X4 Challenge Registration Form

Livingstone 4X4 Challenge Registration Form Livingstone 4X4 Challenge Registration Form About You Give forename and surname as they appear on your passport please Title: Surname: Forename: Known As: Home Phone: Work Phone: Mobile Phone: Post Code:

More information

MCM Korean track program Application for Admission Graduate

MCM Korean track program Application for Admission Graduate MCM Korean track program Application for Admission Graduate Admission Process Checklist Send these five items to the : 1. A completed graduate application for admission. 2. An application fee in the form

More information

Southeast Unity Youth Ministry Minister Endorsement Form

Southeast Unity Youth Ministry Minister Endorsement Form Minister Endorsement Form Program: UNITEENS Retreat Lock-In List all Youth and Adults below who are attending this SE Unity Youth Event. Once submitted, substitutions and additions must be approved by

More information

2009 2010 SYMPOSIUM REGISTRATION PACKET OFAC License #: CT-13006

2009 2010 SYMPOSIUM REGISTRATION PACKET OFAC License #: CT-13006 2009 2010 SYMPOSIUM REGISTRATION PACKET OFAC License #: CT-13006 **************************** DO NOT WRITE IN THIS AREA ********************************* NAME: APPLICATION STATUS: TRAVEL DATES: NOTES:

More information

APPLICATION INSTRUCTIONS STEPS TO ADMISSION

APPLICATION INSTRUCTIONS STEPS TO ADMISSION APPLICATION INSTRUCTIONS visionbaptistcollege.org 856-767-5056 admissions@visionbaptistcollege.org Thank you for your interest in Vision Baptist College, a ministry of Solid Rock Baptist Church. The purpose

More information

CONSENT FOR MEDICAL TREATMENT

CONSENT FOR MEDICAL TREATMENT CONSENT FOR MEDICAL TREATMENT Patient Name DOB Date I, the patient or authorized representative, consent to any examination, evaluation and treatment regarding any illness, injury or other health concern

More information