Personal Information:

Name (as it appears or will appear on your passport):

Preferred Name: Occupation:

School Address (Students - give school name & box number):

City: State: Zip Code:

Phone Number: Cell Phone Number: FAX Number:

E-Mail Address: Passport Number:

Date of Passport Expiration: Issuing Country:

Social Security Number: Date of Birth Age:

School Classification: Major:

Spanish Language Proficiency:

For University Students Only:     Please provide your home / alternate address when not at school.

Street Address: P.O. Box:

City: State: Zip Code:

Phone Number: E-Mail Address:

Date in the spring to start sending mail to this address (after school):

Nearest/Preferred Major Airport to you at time of departure:

Physical:

In Case of Emergency Notify:

Name: Relationship:

Street Address: P. O. Box:

City: State: Zip Code:

Phone Numbers     Home: Work: Cell:

FAX Number: E-Mail Address:

Do you have any Physical Limitations? Yes  No   If yes, please describe:

Are you presently taking any medication or are you under a doctor's care? Yes No

    If yes, please describe:

Allergies?  Please note any allergies to foods, medications, environment, etc.:

Spiritual

How long have you been a Christian? 

Church Preference:      

Name of Congregation where you are a member:    

Address:

City:    State:   Zip Code:

Briefly describe your relationship with God  --  where you have come from and where you believe God is leading you:  

Why do you feel God is calling you to serve as an intern in the Dominican Republic? 

What are your expectations for this summer experience?

Please explain any domestic or international ministry / mission experience (including camp counseling, working with children, previous internships, etc.):

What qualities can you bring to the program by serving as an intern?

What do you feel are your greatest strengths / weaknesses?

Describe any teaching / leadership experience that you have:

Describe various skills, hobbies, talents, and interests that may be useful to serving in an internship (music, drama, athletics, etc.):

Please list any language skills, especially Spanish and /or Creole (Haiti), and note travel experience outside the USA:

Are you parents supportive in your desire to serve the Lord through this internship?  Explain why you feel this way.

How did you hear about Manna / DR and this Summer Internship opportunity?

Please share anything else that you would like for us to consider in your application for this internship:

References*  (please provide the names of two (2) persons that we may contact as character references):

            *NOTE:          All references provided will be personally contacted in regard to this internship.

Name: Address:

City: State: Zip Code:

Phone Numbers    Home: Work: Cell:

E-Mail Address: Relationship to you:

Name: Address:

City: State: Zip Code:

Phone Numbers    Home: Work: Cell:

E-Mail Address: Relationship to you: