IMPACT ZAMBIA 
INTERN APPLICATION
I am applying for the following:
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ATTACH PHOTO HERE Short term team
Internship (6 or 12 mo)
Long term (3 year+) 
NAME (first) (middle) (last)
AGE SEX DATE OF BIRTH PLACE OF BIRTH
CURRENT ADDRESS
CITY STATE POSTAL CODE COUNTRY
PHONE E-MAIL
NAME OF PARENT(S) OR LEGAL GUARDIAN
ADDRESS
CITY STATE POSTAL CODE COUNTRY
PASSPORT NUMBER EXPIRES SOCIAL SECURITY NUMBER (US)
SINGLE___ SEPARATED___ ENGAGED___ DIVORCED___ MARRIED__
CHILDREN (name, age, sex, birthdate)
EDUCATION
________________________________________________________________________________
LAST GRADE COMPLETED DEGREE(s) WHERE
________________________________________________________________________________
________________________________________________________________________________
HOME CHURCH
_______________________________________________________________________________
ADDRESS PHONE YOUR PASTOR
________________________________________________________________________________
LENGTH ATTENDING THIS CHURCH FELLOWSHIP: ______________
LIST ANY DISCIPLESHIP SCHOOLS YOU HAVE ATTENTED AND WHEN:___________________________________________
_______________________________________________
LIST ANY MISSIONS EXPERIENCE:
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
HEALTH
DESCRIBE YOUR HEALTH: EXCELLENT__ GOOD__ FAIR__ POOR__
LIST ANY ALLERGIES: ________________________________
_______________________________________________
LIST ANY MEDICAL LIMITATIONS: _________________________
___________________________________________________________________
DO YOU HAVE MEDICAL INSURANCE COVERAGE: _______________
COMPANY AND POLICY NUMBER: _____________________________
DO YOU SMOKE: ___ DO YOU DRINK ALCOHOL: ____ IF YES, TO WHAT EXTENT?: _____________________________________
HAVE YOU EVER BEEN ARRESTED: __________ WERE YOU CONVICTED: ___ ________________________________________________
HAVE YOU EVER BEEN ACCUSED OR CONVICTED OF SEXUAL MISCONDUCT OF ANY NATURE? _______ IF YES EXPLAIN __________________________________________________________________ _________________________________________________________________________________________
EMPLOYMENT EXPERIENCE
_________________________________________________________________________________________
WHEN WHERE FUNCTION
_________________________________________________________________________________________
WHEN WHERE FUNCTION
_________________________________________________________________________________________
WHEN WHERE FUNCTION
DO YOU HAVE ANY DEBT: ____ IF YES, PLEASE EXPLAIN: ___________________________________________
_________________________________________________________________________________________
WHAT FOREIGN LANGUAGES DO YOU SPEAK: ____________________________________________________
LIST SKILLS, TALENTS, OR GIFTINGS: __________________________________________________________
How long have you been a "born‑again" Christian? __________________________________________________
List your musical abilities: _____________________________________________________________________
Have you led worship? yes no
Have you had military experience? yes no
APPLICATION
1. Application fee of $20 USD must be included with the application. For costs of the various opportunities see the Cost Page.
2. Medical insurance is required.
3. For short term team it is required to have a team leader. IMPACT ZAMBIA will direct the areas of service, adventure and mission, but your local team leader is responsible for the leadership, conduct and welfare of the team.
4. ALL PERSONAL AND MEDICAL EXPENSES ARE THE RESPONSIBILITY OF THE INDIVIDUAL, NOT IMPACT ZAMBIA.
5. ALL PAYMENTS IN US DOLLARS
MY COMMITMENT:yy
I, (please print) _____________________, agree to live by the rules, standards and general guidelines while at IMPACT ZAMBA. I will submit to the oversight of godly men and women in my life. I will apply myself to the pursuit of learning to be a disciple of Jesus: living in Him, learning His ways, obeying His commands, and becoming a fruitful member of His body.
______________________________________________
SIGNATURE DATE
SUPPLEMENTAL QUESTIONS
On a separate piece of paper please number and type answers to the following questions. Please be specific and detailed, yet concise.
1. Please describe your conversion experience and present spiritual relationship with the Lord.
2. What areas of your character are you presently seeking God to further develop and improve?
3. Please describe spiritual experiences that have been significant to you.
4. Please describe your spiritual and/or ministry goals, including missionary service goals.
5. How would you describe your relationship with your family. How do they feel about
your plans to come to this trip?
6. Are you presently employed or in school? Please specify type and length of involvement.
7. Describe your relationship with your local church. Please include areas of ministry,
service, leadership experience, gifts and abilities.
8. How does your church and pastor feel about your plans?
9. Do you now have or have you ever had any physical disabilities or do you have any
special dietary needs? If so, describe them and tell how long you have had them. Please
note that your response to this question is merely for our logistical information and does not
influence your acceptance.
10. List anything else you would like to tell us about yourself that may have a bearing on
your acceptance.
11. Please describe three of your strengths, and three of your weaknesses.
12. Have you had any sexual relaionships outside of marriage in the last 12 months? Explain.
13. Have you had sexual fantasies of a deviant nature? How intense? Have you ever acted on them? Have you ever talked to anyone about this?
12. What biographies have influenced you the most and why?
Name ____________________________________________Relationship _________________________
Address ________________________________City ____________________State _____ Zip_________
Country_________________________________Telephone_____________________________________
Signature _______________________________ Date__________________________________________
I do hereby release IMPACT ZAMBIA, ALL NATIONS, LOVES DOOR, OPEN DOOR COMMUNITY CHURCH, ALL NATIONS its agents, employees and volunteer assistants from any liabilities whatsoever arising out of any injury, damage or loss which may be sustained by said person during the course of involvement with Mandate Schools
.
Name of Applicant ________________________________________________________________________
Applicant's signature ____________________________________________ Date______________________
(or person responsible if applicant is under eighteen years of age)
Relationship to applicant (if applicable)________________________________________________________
I hereby agree to the performance of such treatment, anesthetics and operations as in the opinion of the attending physician is deemed necessary.
Name of Applicant _____________________________________ Date________________________________
Applicant's signature_____________________________________
(or person responsible if applicant is under eighteen years of age).
CONFIDENTIAL REFERENCE FORM
Please fill in your name and address below, then make three copies of this reference form. Give one to
each of the following: a pastor or church leader, another adult ( such as an employer) , and a friend who has known you over 3 years.
Give each of these people a stamped, addressed envelope so they can return the form directly to us. Fill in the
fourth form yourself. Please grade yourself as you see yourself, not as you think others see you, nor as
you think you should be seen.
Name of applicant: _______________________________________________________________________
Address_____________________________ City_________________ State____ Postal Code____________
Country________________________________________________________________________________
Please check the appropriate statement and sign the waiver below.
____ I have waived my right to see this and other recommendations.
____ I have not waived my right to see this and other recommendations.
_____________________________________ Applicant's signature
This applicant is applying for a mission experience with IMPACT ZAMBIA, and is asking you to furnish a reference. We appreciate your careful evaluation. Please complete this form.
How long have you known the applicant?____________________________
In what relationship? Teacher Pastor Friend Employer Adviser Other ____________
Please rate the candidate by checking one or more items under each of the headings below. If possible, describe briefly and concretely specific instances which support or interpret your judgment. Use additional paper if necessary. Do not check items of which you feel uncertain or in which you have had no opportunity to observe.
1. Christian commitment and character
Clearly‑fully committed to Christian values and lifestyle
At times commitment to Christian values is not strong
Has difficulty being committed to Christian values
No basis for evaluation
2. Church involvement
Very active in attendance and ministry
Church leaders support applicant in pursuing education and possible future ministry
Attends but is not active in ministry
Attendance is inconsistent
No basis for evaluation
3. Teachability
Very open to new insights and perspectives
Able to discuss different views without defensiveness
Has strong opinions and tends to be argumentative
Rigid and opinionated
4. Study skills
Well disciplined, completes work well in advance
Somewhat undisciplined but completes work on time
Sometimes work is late and quality limited
Easily distracted; has difficulty completing work
No basis for evaluation
6. Perseverance
Works hard and completes even difficult tasks
Usually completes tasks
At times gets distracted and does not finish tasks
Frequently does not finish tasks
No basis for evaluation
7. Relationships
Enjoys many positive relationships
Sensitive to the feelings of others
Positive influence on others
Has a few close friends
Has difficulty making and keeping friends
Frequently offends others
Detrimental influence on others
Inappropriate at times in mixed settings
Insensitive and intolerant of others
No basis for evaluation
8. Emotional stability
Well balanced; is able to handle stressful circumstances
At times impatient and easily frustrated
Frequently upset by relatively minor circumstances
Frequently seems tense and anxious for no obvious reason
At times moody and difficult to be around
No basis for evaluation
9. Financial responsibility
Positive employment history
Responsible with financial obligations
Has a budget
Has difficulty keeping jobs
Frequently irresponsible with financial obligations
No basis for evaluation
10. What is the applicant's response toward authority?
_________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________________________________________
11.The applicant will be living ‘in community' housing situation, do you believe that he/she will relate in a positive way to other students or will he/she be disruptive in any way_________________________________ __________________________________________________________________________________________
12. Please describe the applicant's home relationships. ________________________________________________________________________________________
__________________________________________________________________________________________
13. Does the applicant over‑emphasize any doctrinal or personal views? _________________________________________________________________________________________
__________________________________________________________________________________________
14. To the best of your knowledge has the applicant*...
Been convicted of a felony Yes No
Engaged in sexual misconduct in the last two years Yes No
Been involved in homosexuality or the occult Yes No
Has there been sexual terauma, sexual abuse or sexual
habits or patterns of behaviour that have caused the
applicant to struggle or fall in their walk with the Lord Yes No
Been dishonest or of questionable character Yes No
Used illegal drugs in the last year Yes No
Used alcoholic beverages in the last year Yes No
Used any tobacco product in the last year Yes No
Been dismissed from any school or college Yes No
If you answered 'yes' any part of question 14, please use this space below for explanation
__________________________________________________________________________________________
__________________________________________________________________________________________
For additional comments: _____________________________________________________________________
__________________________________________________________________________________________
15. Please comment briefly on the family and social background of the applicant. Such as: are the parents divorced? _______________________________________________________________________________
Was their family a healthy one? Does the applicant struggle because of any aspect of his/her upbringing?______
__________________________________________________________________________________________
__________________________________________________________________________________________
16. Is the applicant responsible for his/her financial obligations? Is he/she in debt?____________________________________________________________________________________
__________________________________________________________________________________________
17. To the extent that is common knowledge, please describe any physical limitations the applicant may have.
Similarly, has the applicant had psychiatric treatment? Please explain below: _________________________________________________________________________________________
__________________________________________________________________________________________
Would you recommend the applicant for a missions experience with IMPACT ZAMBIA?
Yes With some reservations (please explain) No (please explain)
Signature _________________________________________ Date__________________________________
________________________________________________________________________________________
Your name (please print) Phone
________________________________________________________________________________________
Address City State Postal Code Country
Please mail this form directly back to the LOVE'S DOOR. Do not give it to the applicant to mail to us.
LOVE'S DOOR
339 NW Sherman St.
Sheridan, OR 97128
503-843-6736 - office
