Please print, complete and return to
1704 Weber, Houston, Texas 77007
Impact Houston Church of Christ
Application for Summer Internship in Urban Youth
Ministry
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General Information:
Name:_____________________________________ SSN:______-____-______
School Mailing Address:______________________ Phone:(____)___________
______________________
Email:_____________________________________
Driver's License:____________________________ D.O.B._____-_____-______
How many moving violations have you had in the past 3 years?_____________________
(Please describe on the back of this page)
Do you have any experience driving 15 passenger van or other large vehicle?__________
Parent's Name(s):___________________________ Phone:(____)_____________
Parent's Address:___________________________
___________________________
How do you plan to be funded?______________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________
References
Name Mailing Address Phone
1)______________________________________________________________________
2)______________________________________________________________________
3)______________________________________________________________________
Personal
What school do you attend?_________________________________________________
What is your classification?_____________________ Major?__________________
Please list your last two employers and briefly describe the position you held:
1)______________________________________________________________________________________________________________________________________________________________________________________________________________________
2)______________________________________________________________________________________________________________________________________________________________________________________________________________________
What extra curricular activities are you involved in? (Use the back of this
page if necessary):_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
* Describe your cross-cultural experience, if any, that you might consider a relevant learning tool towards urban ministry (Use back if necessary):_______________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
What ministry emphasis do you wish to participate with this summer (circle one):
High School ------------ Middle School ------------ VBS
* Describe your approach to discipline in youth involvement:________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
* How do you think you can best contribute to this ministry this summer?______________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________MEDICAL
MEDICAL INFORMATION & RELEASE FORM
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_________________________________________
Last Name ............First Name............... Middle Initial
____________________
Date of Birth
Social Security Number ________-______-_________ ..........Sex: Male Female
______________________________________________ _______________________
Parent/Guardian Name ..................................................................Relationship
_______________________________________________________________________________
Address City/State Zip Code
___________________________________ ___________________________________
Home Phone (include area code) Work Phone (include area code)
If not available in an emergency, please contact:
Name ___________________________________ Phone Number (______)_________________
Family Physician __________________________ Phone Number (______)_________________
Insurance co. ____________________________ Phone Number (______)_________________
Address________________________________________________________________________
Insured's Name _____________________________ Relationship__________________________
Insured's SSN ___________________________ Group # _______________________________
HEALTH
I consider my health to be: excellent fair poor Contact Lenses? Yes
No
Special Needs (i.e., diet restrictions, physical restrictions, etc.)____________________________
______________________________________________________________________________________________________________________________________________________________
Problems requiring special attention ________________________________________________
______________________________________________________________________________________________________________________________________________________________
Allergies and Typical Reactions ____________________________________________________
______________________________________________________________________________________________________________________________________________________________
List all medications you will bring with you to Impact including the dosage
and reason for the medication_____________________________________________________________________________________________________________________________________________________
HEALTH HISTORY
Please check all that you have ever had:
___ Asthma ___ Diabetes ___ Congential Defect ___ Hepatitis
___ Seizures ___ Emotional Problems ___ Migraine Headache
___ Rheumatic Fever ___ Nervous Stomach ___ Broken Bones ___________________
___Operations__________________________________________________________________
Please write a brief Personal Testimony of how you became a Christian and state your present commitment to the Lord Jesus Christ: