International Internship Application

Last Name
First Name:
Middle:
Preferred Name or Nickname:
Facebook link:
Blog site:
   
Permanent Residence:  
Street Address
City
State / ZIP
 
Current place of residence (if different from above):
Street Address
City
State / ZIP
   
Home Telephone Number:
Work Telephone Number:
Cell Phone Number:
College Telephone Number:
E-Mail Address:
Date of Birth:
City of Birth:
County of Birth:
State of Birth:
Citizenship:
Do you have a current passport? Yes      No
Social Security Number
Marital Status: Single      Married      Widowed
If Married, Full Name of Spouse:
Should you be assigned, would your spouse accompany you? Yes      No
Maiden Name / Wife's Maiden Name
Date of Marriage
   
Emergency Contact Information:
   
Emergency Contact 1.  
Name
Relationship
Home Phone
Work Phone
Street Address
City
State / ZIP
Emergency Contact 2.  
Name
Relationship
Home Phone
Work Phone
Street Address
City
State / ZIP
   
Personal Analysis:
Your physical health is: Excellent   Good   Fair   Poor
(if "fair" or "poor", please explain.)
List any physical impairment, chronic disease, or other disability
List any medications and allergies
Describe history of any ongoing physical problems and treatments
Your emotional health is: Optimistic
Pessimistic		 Cheerful
Easily Discouraged
Describe any emotional or nervous problems and treatments
Describe your temperament and how you adapt to new and unexpected circumstances
Describe how you get along with:  
Your family
Peers
Authority figures
Team members
What personal experience have you had living with/around people who are emotionally, psychologically, spiritually different from you?
How did you respond?
Please describe in at least 200 words your personal statement of faith. Describe your process of coming to know Jesus Christ as well as your journey with Him to this point.
When do you find yourself in deepest communion with God? What time or place do you feel the most focused in prayer?
Where do you presently attend church?
Are you a member? Yes      No
Name of church
Denomination:
City/State:
Describe any experiences you have had with leading or participating in groups or studies through your church.
List special church outreaches or activities you have participated in
Have you ever been on a missions trip? Yes      No
If so where/when?
Describe your experience
Have you ever been out of the country for longer than 10 days? Yes      No
If so, when/where?
Describe your experience
In addition to English, what language(s) do you speak?
How well? Are you fluent or conversational?
Have you ever been discharged or asked to resign from any job or military? Yes      No
Have you ever been arrested or charged with any violation of any law or ordinance? Yes      No
Do you currently use drugs, alcohol or tobacco? Yes      No
In the past three years have you intentionally viewed pornography? Yes      No
If you responded yes to any of the items above include a brief explanation of each item.
When could you be available for the internship?
In which Country are you most interested, and why?
Would you be open to a different internship? Yes      No
The Home Foundation will provide a percentage of your trip. How do you plan to raise the remainder of your support?
 

Writing Sample:
Please paste your writing sample here. It should be 1-2 pages on a topic of your choice. OR You may provide a link to your blog.
   
Education  
Name of College or University
City/State
Entrance Date
Graduation/Leaving Date
Diploma/Degree
Area of Study
Any relevant coursework
Other previous internship(s)
   
Employment (begin with present job)
Title/Job Description
Name of Employer
City/State
Beginning Date
Leaving Date
Reason for Leaving
   
Title/Job Description
Name of Employer
City/State
Beginning Date
Leaving Date
Reason for Leaving
   
Personal Reference Information Please give complete information.
   
Reference One:  
Name
Type of Reference
Telephone
Street Address
City
State/ZIP
E-mail Address
   
Reference Two:  
Name
Type of Reference
Telephone
Street Address
City
State/ZIP
E-mail Address
   
(If employer, may we contact them?) Yes      No
   
Physical Activity Questionnaire
Height
Weight
Age
What is your level of daily physical activity?
How many times per week do you exercise?
What do you consider exercise?
How long have you exercised routinely?
How much time walking do you spend each day?
Do you have any physical restrictions that could keep you from being active on a daily basis? Yes      No
If yes, please explain:
Do you have any allergies? Yes      No
If yes, please list