OUTREACH - HAITI

Are you on a full or tuition only scholarship?

Full Scholarship
Tuition Scholarship
No Scholarship

Marital status

Single
Married
Divorced

Do you have a passport?

Passport expiration date

Country of Citizenship

Emergency Contact's Email

Are you under the age of 18?

Parent/Legal Guardian Information - Only if you are under 18

Parent/Guardian Phone 1

Parent/Guardian Phone 2

If parents are separated, divorced, or deceased, who has legal custody?

Describe why you made a decision to follow Christ

Describe your current relationship with God

Describe your church involvement

I have been suspended or expelled from school

I have served time in a detention center or jail.

I have been convicted of committing a crime.

I have been involved with tobacco products.

I have been involved with alcohol.

I have been involved with illegal drugs.

I have been involved with gang-related activities.

I have been involved with a cult or the occult.

I have or have had diabetes or hypoglycemia.

I have or have had seizures.

I have or have had fainting spells.

I have a serious illness.

I have or have had an eating disorder.

I have or have had breathing problems.

I have or have had psychiatric care.

I have taken anti-depression or behavior altering medication.

I have been sexually active (omit if married).

I have been pregnant or fathered a child (omit if married).

I have been involved in homosexual activities.

I have intentionally inflicted harm on myself.

I have attempted suicide.

I have been treated for physical impairment.

I have been treated for mental impairment.

If you answered Yes to any of the above, please provide a detailed explanation including dates.

PLEASE NOTE: CFNI Outreach does not hire/send persons who, as an adult, have sexually abused a child.

I affirm I have never, as an adult, sexually abused a child.

I have, as an adult, sexually abused a child.

NOTE: If anything in your present or past medical history is of concern for the Outreach Leader you may be asked to obtain a Medical Release Form from your physician.

What is the condition of your health?

Good
Fair
Poor

Do you have any physical problem that should be considered?

Describe your current medical condition. Include a description of all conditions which may limit your physical and/or mental abilities. For example: asthma, recurring injuries to knees or back, hypoglycemia, allergies to meds/foods/bites, depression, etc.

Are you taking any medication?

Please list all current medication you are taking (include all prescription and non-prescription medications/vitamins).

Are all of your immunizations up to date?

Please choose pastors, friends, co-workers, roommates, etc. who are not family members and who know you well enough to answer personal questions about your life (ie: your gifts in ministry, ability to work in a team, areas of struggle).

Reference #1

(Pastor/Leader you are accountable to)

Relationship to you

Pastor
Teacher
Mentor
Friend

Reference #2

(Pastor/Leader you are accountable to)

PERSONAL INFORMATION

Emergency Contact

Parent/Legal Guardian Information - Only if you are under 18

Personal History

Medical History

References