Children At Risk School | April 2018 Application for Children At Risk School Step 1 of 7 0% Name* First Last Sex* Male Female Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Date of Birth* DD MM YYYY Age*Birthplace*Phone*Email* Please upload a picture of yourself*Marital Status*SingleEngagedMarriedDivorcedRemarriedWidowedSpouse's Name Spouse's Date of Birth DD MM YYYY Please list names and details of children accompanying you:Surname, First Name, Birth Date and SexPlease give contact information for an emergency contact.First and last name, location, relationship to you, phone number and emailPassport InformationDo you have a valid passport?*YesNoName as listed on Passport* Passport No.:*Nationality*Country and City where issued:*Date Issued*Day/Month/YearDate of Expiry*Day/Month/Year Education and ExperienceSummarize your school, post school and Christian education history listing the names of the institutions and the qualification obtained.*Please list any work, ministry or vocational experience and skills.*Give details and dates of full-time positions held in the church or Christian organisations.*Give details of previous Christian training or education you have had through a YWAM location, church or College. Please give name of school, location and dates.*General Health Information (Our programme will require good health and endurance) Are there any abnormalities of the following systems?Ears/Nose/Throat* Yes No If yes, please describe fully.Eyes* Yes No If yes, please describe fully.Neurological* Yes No If yes, please describe fully.Cardiovascular* Yes No If yes, please describe fully.Respiratory* Yes No If yes, please describe fully.Musculoskeletal* Yes No If yes, please describe fully.Dermatological* Yes No If yes, please describe fully.Urological* Yes No If yes, please describe fully.Any other medical condition not mentioned above?Do you smoke?* Yes No Please specify what, how much and how oftenDo you drink alcohol?* Yes No Please specify what, how much and how oftenPlease be aware that YWAM Muizenberg has a NO SMOKING/NO DRINKING policy that you will need to abide by while attending Children At Risk School.Would you be able to be on your feet and do physical work for up to 8 hours a day?* Yes No Give details of any medication you are presently taking or doctor’s treatments you are under.If you have struggled with any of the following in the last two years, please explain: nervous breakdown, depression including manic depression, “burnout” or had M.E. (chronic fatigue). Do you still need help in this area?Skills and InterestsWhat are your interests and hobbies?*List your abilities and talents.*What languages do you speak, read and write (in order of fluency)?*Personal BackgroundDue to the nature of this school, there is certain information regarding your past that is important for us to know. We ask for you to be as sincere as possible in answering these questions, if there is anything else you feel we should know please use the final box to do so. We would like to stress that this application is strictly confidential.Are there any past experiences (i.e. drug or alcohol addiction, homosexuality, extramarital activity etc.) which we should know about as we consider your application?*Were you a victim of child abuse?*If 'yes' who was the abuser?Have you ever abused or mistreated a child?*Have you ever been arrested?*Please give relevant history if you have been divorced, separated or remarried.Do you currently have any charges pending against you?*Are you still receiving help in any of the above areas? Would you appreciate counsel should you be accepted?* Christian Life and CallPlease describe how you came to know Jesus personally.*Please describe your present personal relationship with the Lord. Are there areas of your character that you are presently seeking to further develop and improve?*How did God lead you to apply to this school?*Do you feel that God is leading you or have a specific interest in any particular area of ministry (children, arts, music, teaching, sports, administration, hospitality, maintenance, etc.)?*Please describe your involvement with your local church. Are they supportive of your participation in YWAM?*How would you describe your relationship with your family? Are they supportive of your participation in YWAM?*Do you feel that you can live in possibly unfamiliar conditions: i.e. mixed cultures & races, different food, limited living space, no running water? If not, please share.*What do you think you might want to do after this course is finished?*Is there anything else you would like to share with us about yourself?* Financial InformationDo you have any outstanding debt?*YesNoWhat is the amount you owe and how do you propose to meet your obligations:*Are you financially obligated to any dependents?*YesNoPlease describe where you are at in the fund raising process and how you plan to raise the funds needed.*Do you have committed monthly support?*YesNoAmount of Monthly Support?* Financial DeclarationWill you be arriving with all your school fees?:*If no please tell us how much you will have in Rand on arrival to the school (ZAR):How are you already fund raising to see the outstanding amount of this come in?:*Do you have financial support for doing the school (if so how much?):*Do you have any outstanding debt?:* Yes No If yes how and when will this be repaid?:Digital Signature (type your name)* First Last Date* Partnership AgreementWaiver and Release of Liability // l do hereby release Youth With A Mission, its agents, employees, and volunteer assistants from any liability whatsoever arising out of any injury, damage, or loss which may be sustained by myself or other persons during my course of involvement with Youth With A Mission.* Yes I Agree Consent for Treatment // In the event of an emergency in which I am rendered unconscious and my nearest responsible relative or guardian cannot be contacted, hereby agree to such treatment, anesthetics, and operations to be performed upon myself as in the opinion of the attending physician (s) is deemed necessary.* Yes I Agree Financial Responsibility // l confirm that I have read and understand the YwAM Muizenberg Financial Policy. understand and accept that thepayment of the required school fees must be made prior to or at registration, unless otherwise approved in writing by the Training Director before my arrival in Muizenberg. Further, responsibility and agree to meet prior to the completion of the school all personal expenses incurred during my involvement with Youth With A Mission.* Yes I Agree Declaration // l declare that all information that I have supplied in my application is true, to the best of my knowledge. accurate, and complete* Yes Digital Signature (type your name)* First Last Date* If the applicant is under 18 years of age, then the signature of a parent/quardian is also required.Parent Guardian Name First Last RelationDigital Signature (type your name) First Last Date Please click the submit buttonThank you so much for taking the time to fill out this application form. If for any reason the application is unable to submit, please try one more time. If that doesn't work, you can go to http://ywammuizenberg.org/apply/ and download the application from there and email it to registrar@ywammuizenberg.org. Thank you!
