DNA Infusion DNA Infusion application Step 1 of 5 - Personal Information 20% Personal InformationName* First Middle Last Sex* Man 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 GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe LanguageDate of Birth DD MM YYYY Age*Email* Telephone Number* Passport InformationCountry of Birth*Name on Passport*Passport No.*Expiry Date of Passport*Family InformationMarital Status*SingleMarriedDivorcedWidowedSpouse’s Name: (If married)Spouse’s Date of BirthSpouse’s AgeUnder 1818-2425-3435-4445-5455-6465 or AbovePrefer Not to AnswerList names/ages/gender of children accompanying you Emergency Contact InformationName of Emergency ContactRelationshipTelephone NumberEmail AddressPreferred Language of Communication YwamRelationship with Ywam*DTS Location*Date Lecture phase completed* Date Outreach phase completed* Please give a brief description of your leadership (DTS leader, King’s Kids,etc)* Partnership AgreementWaiver and Release of Liability // I do hereby release Youth With A Mission, its agents, employees and volunteer assistance 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 do 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, I 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 do Financial Responsibility // I understand and accept that the payment of the required seminar fees must be made prior to or at registration. Further, I take full responsibility and agree to meet prior to the completion of the seminar, all personal expenses incurred during my involvement with Youth With A Mission.* Yes, I do Declaration // I declare that all information that I have supplied in my application is true, accurate and complete to the best of my knowledge.* Yes Digital Signature (type your name)*Date* If you are applying for the 6 week LTS, you do not have to fill in a DNA application. The DNA Infusion is in week 4 and 5 of the LTS.