Name

Date of birth

(MM/DD/YYYY)

Address

City, state

Postal code

Phone (home)

Phone (cell)

E-mail

Congregation

Region

Are you available for assignment from May 23 to August 9, 2009, without conflict?
Yes     No

Do you expect to have a vehicle on-site?
Yes     No

How did you first hear of the intern program?

Experience

Work history: include dates/places/responsibilities

Please list any experiences you have had in these or similar areas: mission trips, camping, scouting and/or outdoor ministries, youth and young adult events. Include event/place/start and end dates.

Health

Do you have any health issues that would affect your ability to fulfill the intern’s tasks?
Yes     No

Please note any present or past health concerns, including any medications you are currently on.

Do you have health insurance?
Yes     No

If yes, include company name, group number and name of sponsor/member:

References

Please provide the name and contact information for three professionals (ministers, professors, counselors) who know you well, including your home or campus pastor. Then, refer each of your references to the reference form which is available online.

Reference Name 1

Address

City, state

Postal code

Phone

E-mail address

Reference Name 2

Address

City, state

Postal code

Phone

E-mail address

Reference Name 3

Address

City, state

Postal code

Phone

E-mail address

Self reflection

Please respond to each of the following in as much space as you need.

1. Describe an area of your life where you have recently grown in your Christian faith. How did you see God at work in the process?

2. Describe an experience you have had with a person or a group of people from another race or culture. What, if any, impact did that experience have on your life?

3. What has led you to apply for a Disciples Home Missions intern position? What skills, knowledge, experience do you see yourself contributing?

Please review the Mission Centers found on the web.

a. In which area of service would you find yourself most challenged? Why?

b. Which area of service would you prefer? Why?

Self Assessment

Rate yourself in these categories according this scale:
1=outstanding; 2=good; 3=satisfactory; 4=fair; 5=poor; U=Unknown.

Think of how you have actually responded in specific situations and not how you hope you might respond. If you have not experienced some of the given situations, enter the letter U for "Unknown." Add a comment where explanations might be helpful and especially where a rating is at either extreme end of the scale.

 Qualities, Abilities, and/or Skills -- The degree to which I feel I have the ability….

Self-Understanding
My Ability to:
1. identify my strengths and weaknesses
2. deal constructively with my feelings and convictions
3. grow and change in response to experiences

Comments

Motivation
My Ability to:
1. define clearly my objectives and motivation for mission
2. derive satisfaction from achievements other than the accomplishment of measurable results

Comments

Cross-Cultural Adaptability
My Ability to:
1. recognize the influence of my own culture on my attitudes, assumptions, values, behavior
2. adjust to different lifestyles, isolation, lack of modern conveniences
3. function effectively when my work is not clearly defined

Comments

Interpersonal Relationships
My Ability to:
1. work with others, especially where there are differences of theological or political beliefs or work objectives
2. participate in the process of planning and decision-making to produce mutually determined goals
3. listen to others

Comments

Authority Relationships
My ability to function effectively when:
1. the lines of authority are blurred
2. there are pre-set policies and procedures
3. authorities are of different races of culture
4. authorities are older or younger

Comments

Someone from Disciples Volunteering will contact you before the first of March.

Questions? Call Brenda Tyler. Members of the Christian Church (Disciples of Christ) will be considered first.