Team Member
Application
Missions Trip 2017
Due Oct. 12 @ noon in E202
Please complete this application and have a Crown College Faculty or
Staff member fill out the reference form. Please print clearly in blue
or black ink. Return completed application to the International
Service Learning (ISL) Office in E202 by Oct. 12th
Full Name (First,
last): _____________________________________________
Phone Number: ___________________________ Box Number: _______________
Year at Crown: __________________
Major: ________________________Email: ________________________________
Birthday: ____________________ Languages spoken: _____________________
1. What are the top three locations of interest? (Number 1 being the opportunity
that you are most interested in)
1. ____________________________________________________________
2. ____________________________________________________________
3.____________________________________________________________
2. Please list any intercultural experiences that you have had.
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3. How would you describe your current relationship with Christ?
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4. What talents/gifts has God given you to minister to others (drama, singing, teaching,
youth work, medical, other) ?
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5. What are your strengths and challenges in the areas of personal relationships and meeting
new people?
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6. What do you expect to learn on this trip? How do you hope to be changed?
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7. What challenges have you faced that might help prepare you for a missions trip?
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8. Is there anything that might hinder your participation in a missions trip?
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9. Briefly tell us how the Lord called you to Himself.
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10.Please rate the following using this scale:
1)no opinion
2)never
3)seldom 4)usually 5)always
A. I seek to set an example by my academic work.
1
2
3
4
5
B. I seek to set an example by my personal integrity.
1
2
3
4
5
C. I uphold the College Community Covenant.
1
2
3
4
5
D. I try to show friendliness toward students, faculty and staff. 1
2
3
4
5
E. I am able to laugh at myself and laugh with others.
1
2
3
4
5
F. I refrain from gossip, sarcasm and depreciation of others.
1
2
3
4
5
G. I am able to keep a confidence.
1
2
3
4
5
H. When I make a commitment, I follow through.
1
2
3
4
5
I. When it is necessary, I will confront a friend.
1
2
3
4
5
J. Others would say that I am approachable.
1
2
3
4
5
K. I am prompt for classes, work, meetings etc.
1
2
3
4
5
L. I make every effort to understand the entire situation
1
2
3
4
5
M. My roommate (or friend) would say I am willing to listen.
1
2
3
4
5
N. Others would say that I am insightful & sensitive to
1
2
3
4
5
1
2
3
4
5
before making a judgment.
their needs.
O. I believe it is important to work through conflicts in my
personal relationships
11. Passport Information
If you are applying to go overseas and do not already have a passport, please apply asap. The
process can take several weeks.
Your name EXACTLY as it appears on your passport:
_____________________________________________
Passport # ____________________________________
Issue Date _____________________________________
Expiration ________________ Issuing Agency __________________________
Birthplace ____________________________________
If you do not yet have a passport, please check here: _________
12. Church Involvement
Are you currently involved in a church? (circle one)
Yes
No
Are you currently serving in a ministry? (circle one)
Yes
No
13. Optional -Health Information (This information is for us to help accommodate where
needed. ) If you prefer, please give the info to Nurse Sophia along with a release of info.
Present health condition (circle one) Excellent Good
Fair
Poor
Explain, if needed: _______________________________________________
Check all that apply and give a brief explanation:
____ Physical disability ________________________________________________________
____ Allergies (meds, food, pets) ________________________________________________
____illness or condition for which you are being treated.______________________________
____ List of all current medications you are taking.__________________________________
Please bring your completed application to the ISL Office E202
by Wednesday
Oct. 12th at noon
You may contact Liz Blancke at [email protected]
ext. 4486 with any questions or concerns.
Destination: Serve Faculty/Staff Reference Form
*This portion is to be Completed by the Applicant*
Faculty/Staff member’s name: __________________________________________________________
Applicant’s full name: _________________________________________________________________
Under the Family Education Rights and Privacy Act of 1974 (Buckley Amendment), which gives students
the right to inspect and review their education records, students may waive their right to see specific
confidential statements and letters of recommendation. In the belief that applicants and the persons
from who they request references may wish to preserve the confidentiality of those references, we are
giving you an opportunity to sign one of the following statements:
_____ I waive my right to examine this form
___________________________________
Applicant’s Signature
Date
_____ I do not waive my right to examine this form
___________________________________
Applicant’s Signature
Date
The applicant named above is applying for a Destination: Serve mission trip. The completed form
should be sent directly to the Office of International Service Learning (ISL) in E202.
1. How long have you known the applicant? _________________________________________________
How well?
_____Very well
_____Rather well
_____Casually
_____Not well
In what capacity? _____________________________________________________________________
2. List three personality qualities that best describe this person and explain why you chose these:
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3. Please explain any personal or spiritual weaknesses or areas for improvement in this person:
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4. Has the physical and/or emotional health of this individual adversely affected his or her
performance? _______________
If yes, please explain: _______________________________________________________________
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5. Please circle the terms which best describe the applicant:
INDUSTRY
o Seeks additional work
o Completes additional suggested
work
o Prepares assigned work only
o Needs occasional prodding
o Needs much prodding
o No opportunity to observe
DEPENDABILITY
o Always dependable
o Usually dependable
o Sometimes dependable
o Undependable
o No opportunity to observe
CHARACTER
o High moral and spiritual
standards
o Shows growth and maturity
o Indifferent moral/spiritual
standards
o Inconsistent attitudes and
practices
o No opportunity to observe
SOCIAL ACCEPTABILITY
o Sought by others
o Liked by others
o Tolerated by others
o Avoided by others
o No opportunity to observe
INITIATIVE
o Highly motivated
o Sometimes initiates
o Succeeds if told what to do
o Needs constant supervision
o No opportunity to observe
SOCIABILITY
o Deeply concerned for others
o Interested and helpful
o Indifferent about others
o Self-centered
o Anti-social
o No opportunity to observe
QUALITY OF WORK
o Does outstanding work
o Does acceptable work
o Is careless in work
o Works very poorly
o No opportunity to observe
LEADERSHIP
o Excellent leadership abilities
o Effective leader
o Supportive, second-in-charge
o Definite follower
o No opportunity to observe
6. On a scale of 1 to 5 how would you recommend this applicant for a short term mission trip? (5 being
highly recommended and 1 being do not recommend)
Do not recommend
1——2——3——4——5
Highly recommend
Explain: ____________________________________________________________________________
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7. As an aid to our evaluation of the applicant, we would appreciate any additional information that you
can provide (on a separate sheet) in terms of specific strengths and weaknesses of the applicant.
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Your Name (Please print)
May we call you if necessary? _____ Yes
Signature
_____No
Date
phone ext. ___________________________