Ethnicity *

African American

Asian/Pacific Islander

Caucasian/European

Multicultural/Global

Native American

Spanish/Hispanic/Latino

Present Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

My present address is effective until the following date: *

MM

DD

YYYY

Permanent Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

*

Home

Cell

Work

Have you ever pled guilty to a felony? *

Yes

No

Church Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Pastor's Phone Number *

(###)

###

####

Please indicate where you would like to serve, if selected: *

Rural Church Setting

Suburban Church Setting

Urban/Inner-city Church Setting

Willing to serve where needed

Many of the host churches provide housing for interns during the internship. This allows for flexibility when matching an intern with a host site. Are you willing to be placed in a host site away from your permanent residence and stay in accommodations provided by the host church? *

Note: interns are responsible for their own transportation.

Yes

No

Age demographics you would most like to work with: *

Children

Youth

Adults

Combination

Which of the following would you be most interested in learning or using at your placement site? (mark all that apply) *

Planning worship

Leading worship

Leading group discussions

Working with community service groups

Organizing and guiding committees

Preaching/Public speaking

Children's/Youth Ministry

Campus Ministry

Pastoral Reference Name *

First Name

Last Name

Pastoral Reference Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Pastoral Reference Phone *

(###)

###

####

Work-related Reference Name *

First Name

Last Name

Work-related Reference Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Work-related Reference Phone *

(###)

###

####

Academic Reference Name *

First Name

Last Name

Academic Reference Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Academic Reference Phone *

(###)

###

####

Personal Reference Name *

First Name

Last Name

Personal Reference Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Personal Reference Phone *

(###)

###

####

Date Signed *

MM

DD

YYYY