RCOA’s Educational/Missions Trip
Application Form – March 2017
We need to find out about who you are, where you're headed, what you've been doing, and what you're
good at! Please print this application form and take your time to fill it out thoughtfully, ensuring that you
give us an accurate picture of what makes you tick. Please send your application form with a $100 nonrefundable deposit and a Parent’s Funding Agreement form to:
Mark Langley
c/o RCOA
#105 – 4475 Viewmont Avenue
Victoria, BC V8Z 6L8
Section 1: Personal Info.
1. Legal Name _______________________________________________________________________
(First, middle and last, as shown on your birth certificate)
2. Usual Name (if different) ______________________________________________________________
3. Student’s email address _____________________________________________________________
4. School of Record _________________________________________________ Grad Yr. _______
Are you enrolled as a DL student with RCOA?
Y
N
If yes, please select the Spanish course and Cross Cultural Missions course for 2016-17.
If no, please go to our website www.rcoa.ca, click Admissions, and fill out a DL Enrolment form.
Please note your School of Record and request the appropriate Spanish and Cross Cultural
Missions course for 2016-17.
Which Spanish course do I choose? Introductory Spanish 11 (I Spanish 11) is entry level. I
Spanish 11 is the prerequisite for Spanish 10, which is the prerequisite for Spanish 11.
5. Name(s) of Parent(s)/Guardian(s)_______________________________________________________
6. Parent’s email address ______________________________________________________________
7. Physical Address ___________________________________________________________________
City ________________________ PC __________________________ Phone (
) _______________
8. Do you have a valid* passport? # __________________ Expiry ________________
(Please attach a copy of the first page of your valid passport)
* There should be at least 6 months left on the passport before it expires in order for it to be valid.
9. Have you had your shots? ___________
10. What language(s) do you speak? (S=Speak, R=Read, W=Write)
Language
English
French
Spanish
Other ______
Limited
Fairly Well
Fluently
SRW
SRW
SRW
SRW
SRW
SRW
SRW
SRW
SRW
SRW
SRW
SRW
Section 2: Medical Info.
1. Name of Family Doctor _______________________________________________________
Telephone ( ) ____________________ Fax ( ) ____________________________
2. Medical Insurance: Province ________ Number ________________
Private: Company___________________________________ Number__________________
3. What was your overall state of health during the past year? Excellent, Good, Poor ...
Please explain:
_________________________________________________________________________
_________________________________________________________________________
4. Do you take any medication regularly? Yes No
If "Yes" please list name(s) of medication(s) and why you take them:
____________________________________________________________________________________
____________________________________________________________________________________
5. Do you have any allergies? Yes No If "Yes" please list:
____________________________________________________________________________________
6. Please list any physical limitations or dietary needs that we should know about.
___________________________________________________________________________________
____________________________________________________________________________________
7. Please list any special care or considerations you'll need...
____________________________________________________________________________________
____________________________________________________________________________________
Section 3: You, Your Friends & How You Relate
1. Which of the following describes you best? Check off as many as you wish.
I love adventure
I like to organize events
I'm physically active
I'm basically quiet, but friendly
I'm not all that active, but willing to try just about anything
I'm pretty handy with the computer, e-mail, surfing
the net, etc.
People tell me that I'm easy to get along with
I hope there's a TV in my room
Okay, I've been a bit of a pain, but I'm serious about getting
deeper with God
I like the idea of a building project, rather than
drama or music
I'm quite active in my youth group
Teaching children or working in an orphanage
attracts me.
I usually enjoy the classroom experience and have done
pretty well in my studies.
I'm more oriented towards travel, adventure and
service than academics
I'd like to learn another language as part of my study
I enjoy reading a lot
2. Other people describe me as: (Check off as many as are appropriate to you.)
A leader
Challenging... I often push the
edges
A good athlete
Pretty quiet
A team player
Nice, but a little hard to get to know
Pretty much normal
A thinker
A servant, I love to help people
Life of the party
A little odd at times
A good student
Artistic
A hard worker
Funny
3. Tell us a bit about how you're relating to God and God's people right now.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
4. Who/what is the most important person/people/object you'll leave behind when you leave home?
______________________________________________________________________________
Section 4: Guatemala and you
1. What will be your biggest challenge on this short term Mission Trip?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
2. What do you feel are the three best reasons for you to attend this mission trip?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
3. What's the long-term plan for your life? Any special plans or aspirations you're considering or dreaming
about?
____________________________________________________________________________________
____________________________________________________________________________________
4. After I graduate, I plan to:



work for awhile
go to College or University (which one?) __________________________________
other _______________________________________________________________
Section 5: Music/Drama/Sports etc.
1. Do you play an instrument(s)? Yes No If "Yes", please list _______________________
2. Do you prefer team sports like volleyball or basketball or sports you can do on your own like skiing or
track?
______________________________________________________________________________
3. What phrase(s) below would best describe your level of physical activity?
Couch potato, I mostly hang around.
I work out regularly on my own.
Short walks to 7/11 for a slurpee etc.
Bungee jumping & mountaineering are in my blood
The odd ball game is a lot of fun to play
I'm training pretty seriously
I'm part of a sports team
Health issues have made me a great spectator
4. Do you have any teaching experience? Yes / No... Please list/describe.
____________________________________________________________________________________
5. Anything else that you love to do that might contribute to the whole experience?
____________________________________________________________________________________
Section 6: ...Your Turn
Please tell us some things about yourself. What is it about you and this program that makes it feel like a
good choice?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Your Commitment
We at Regent Christian Online Academy believe that God, through Jesus Christ, has taken the initiative
to restore the relationship between humans and God. People who accept this grace of God are forgiven
and restored.
A fascinating life of discovery, community and "day by day walking" with God and his people follows.
It is important that you... (if you agree, please initial each statement)
I agree ______ Are a seeker, committed to growth in your understanding of Jesus Christ and exploring
life as a Christian.
I agree ______ Are willing to place yourself under the authority of, and work with RCOA staff.
I agree ______ Are ready to identify with and participate in the activities of the churches and the
communities wherever you go with RCOA.
I agree ______ Are willing to be flexible, adjusting to new ideas and cultures wherever you go. This
means being grateful for humble accommodations and eating what is set before you
(except in cases of known food allergies).
I agree ______ Are willing to live within a group, and work at problems and human relations with honesty
and openness.
I agree ______ Are willing to live simply and healthfully, respectful of other cultures and beliefs.
I agree ______ Are willing to apply yourself to work diligently at the Spanish course and Cross-Cultural
Missions course, including completing all homework.
I agree ______ Are willing to set a good example of servant/leadership when working and volunteering in
Guatemalan work sites.
I agree ______ I understand that smoking, drinking alcohol, and taking illegal drugs is absolutely
prohibited on this trip.
I agree ______ At times the Leadership Team may require you to park your mobile device in order to be
more available to form relationships, to drink in the culture, and to obtain the most from
this Cross Cultural experience.
Females Only
I agree ______ I understand that short shorts, strapless shirts, tank tops and other revealing apparel are
not acceptable in this conservative culture.
Date _____________________ Signed____________________________________________
Guardian __________________________________________ (If applicant under 18 years of age)
Please mail this completed form back to RCOA at:
RCOA
Attn: Mr. Mark Langley
#105 – 4475 Viewmont Avenue
Victoria, BC V8Z 6L8
IMPORTANT CHECKLIST:



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I have included my $100 cheque, non-refundable deposit
I have included a copy of my valid passport
I have completed the online DL admission form as laid out on page 1 of this application
I have included a signed Parent’s Funding Agreement form