Today's date*
First Name*
Last Name*
Name you prefer to be called.
Name
Date of Birth*
Address*
City*
State/Province*
Select State or Province Alabama Alaska Alberta American Samoa Arizona Arkansas Armed Forces America Armed Forces Other Areas Armed Forces Pacific British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Marshall Islands Maryland Massachusetts Michigan Micronesia Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Islands Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Palau Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Country other than US or Canada
Postal Code*
Phone (home)*
Phone (cell)*
E-mail Address*
Congregation*
Region*
Select Your Congregation's Region. Christian Church in Alabama and Northwest Florida Christian Church in Arizona Christian Church of Northern California-Nevada Christian Church of the Pacific Southwest Christian Church in Canada Central Rocky Mountain Region Christian Church in Florida Christian Church in Georgia The Great River Region Christian Church South Idaho Christian Church in Illinois and Wisconsin Christian Church in Indiana Christian Church in the Upper Midwest Christian Church in Kansas Christian Church of Greater Kansas City Christian Church in Kentucky Christian Church Michigan Christian Church of Mid-America Christian Church in Montana Christian Church in Nebraska Christian Church - Northeastern Region Christian Church in North Carolina Christian Church in Ohio Christian Church in Oklahoma Christian Church in Oregon Christian Church in Pennsylvania Christian Church in South Carolina Christian Church in Tennessee Christian Church in the Southwest The Christian Church in Virginia The Northwest Regional Christian Church Christian Church Capital Area Christian Church in West Virginia
Student?*
Please Select Yes No
If yes, where are you currently enrolled?
Enrollment*
Academic Year
Course of study*
Anticipated vocation*
High School*
Are you available for assignment from May 26 to August 4, 2012, without conflict?
Availability*
Yes No
What is your home city (from where will you travel to your summer placement)?
City*
If needed, would you have a vehicle available for the summer?
Vehicle*
Yes No
How did you first hear of the intern program?
Hear of 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.
Experiences List*
Please indicate your skill level in any language other than English:
Example: B) Spanish
Language List
Health
Do you have any health issues that would affect your ability to fulfill the intern's tasks?
Health Issues*
Yes No
Please note any present or past health concerns, including any medications you are currently on.
health Concerns*
Do you have health insurance?
Health Insurance*
Yes No
If yes, include company name, group number and name of sponsor/member.
Health Insurance Information
References
Please give the name and contact information for three professionals who know you well. Then, refer each of your references to the reference form which is available online .
Your current pastor
Name*
Address*
City*
State/Province*
Select State or Province Alabama Alaska Alberta American Samoa Arizona Arkansas Armed Forces America Armed Forces Other Areas Armed Forces Pacific British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Marshall Islands Maryland Massachusetts Michigan Micronesia Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Islands Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Palau Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Country other than US or Canada
Postal Code*
Phone Number*
E-mail Address*
A professor, advisor, or school administrator
Name*
Address*
City*
State/Province*
Select State or Province Alabama Alaska Alberta American Samoa Arizona Arkansas Armed Forces America Armed Forces Other Areas Armed Forces Pacific British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Marshall Islands Maryland Massachusetts Michigan Micronesia Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Islands Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Palau Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Country other than US or Canada
Postal Code*
Phone Number*
E-mail Address*
An adult with whom you have worked in the previous three years.
Name*
Address*
City*
State/Province*
Select State or Province Alabama Alaska Alberta American Samoa Arizona Arkansas Armed Forces America Armed Forces Other Areas Armed Forces Pacific British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Marshall Islands Maryland Massachusetts Michigan Micronesia Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Islands Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Palau Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Country other than US or Canada
Postal Code*
Phone Number*
E-mail Address*
Self reflection Please respond to each of the following in as much space as you need. You might consider typing your responses in a word processor then pasting them into the appropriate form fields.
1. What was the last book or periodical you read that wasn't a class assignment?
Reading*
2. What do you do to relax, unwind, relieve stress, or have fun?
Stress Release*
3. 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?
Christian Faith*
4. Describe an experience you have had with a person or a group of people from another race, religion, culture, sexual identity or economic circumstance. What, if any, impact did that experience have on your life?
Other People*
5. What has led you to apply for a Disciples Home Missions intern position? What skills, knowledge and experience do you see yourself contributing?
Reason for Applying*
Please review the Mission Centers found on the Internet.
In which area of service would you find yourself most challenged? Why?
Challenge*
Which area of service would you prefer? Why?
Service*
Self Assessment Rate yourself in these categories according this scale:
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
Identify*
2. Deal constructively with my feelings and convictions
Deal*
3. Grow and change in response to experiences
Grow*
Comments*
Motivation: My Ability to ...
1. Define clearly my objectives and motivation for mission.
Define*
2. Derive satisfaction from achievements other than the accomplishment of measurable results.
Derive*
Comments*
Cross-Cultural Adaptability: My Ability to ...
1. Recognize the influence of my own culture on my attitudes, assumptions, values, behavior
Recognize*
2. Adjust to different lifestyles, isolation, lack of modern conveniences
Adjust*
3. Function effectively when my work is not clearly defined
Function*
Comments*
Interpersonal Relationships: My Ability to ...
1. Work with others, especially where there are differences of theological or political beliefs or work objectives
Work with others*
2. Participate in the process of planning and decision-making to produce mutually determined goals
Participate*
3. Listen to others
Listen*
Comments*
Authority Relationships: My ability to function effectively when ...
1. The lines of authority are blurred
Lines of Authority*
2. There are pre-set policies and procedures
3. Authorities are of different races of culture
Authorities of different culture*
4. Authorities are older or younger
Older or younger*
Comments*
Someone from Disciples Volunteering will contact you before the first of March.
Questions? Contact Brenda Tyler . Members of the Christian Church (Disciples of Christ) will be considered first.
To prevent spam, please tell us:
What is six added to seven?*
