Converge
APPLICATION FORM
Part 1 PERSONAL INFORMATION When do you hope to enroll?
January 2012
May 2012
unsure
Last Name: ___________________________
First Name: ______________________________
Middle Name: _________________________
Maiden Name: ____________________________
Preferred First Name: ____________________
Other names: ____________________________
Present Address (Here until what date? _____________________) Month / Day / Year _______________________________________________________________________________ Street Number and Name
Apt or Box Number
_______________________________________________________________________________ City
Telephone:
State
Home: (
Country
) ___________________ Mobile: (
area code
Work: (
Zip Code
number
) ___________________
area code
number
) ___________________
area code
number
Email:______________________________________ Birth date: _______________
Gender:
Are you an US citizen? Yes
Male
Female
No
Month / Day / Year
Part 2 – FAMILY INFORMATION Parents’/Legal Guardians’ Names: ____________________________________________________ Do you currently live with your parents/legal guardians?
Yes
No
If No, and you are under age 18, please provide your parent’s address:
Father
Mother
Both
_______________________________________________________________________________ Street Number and Name
Apt or Box Number
_______________________________________________________________________________ City
State
Zip Code
Country
Parent Telephone: Home: ( ) ________________ Parent Email:___________________________ area code
number
Do your parents support your participation in Converge? If No or Unsure, Explain:
Yes
No
Unsure
Your Marital Status: (please circle all that apply) Single Engaged ________ Projected Wedding Date Married – Date: _________ Divorced – Date: _________ Separated – Date: _________ Widowed – Date: _________ If married or engaged, name of spouse/fiancee/fiance:
If you have children please list names and ages of children:
Part 3 - EDUCATIONAL INFORMATION Are you a high school graduate?
Yes ____________
Not Yet _________________ No
Date
Projected Date
If No, have or will you earn a GED? Yes ____________
Not Yet _________________ No
Date
Projected Date
List any other discipleship programs or colleges you have attended (most recent listed first): Name of Organization/Program
Location of Program
Type of
Dates of
Program/Major
Attendance
Completed?
Yes
No
Yes
No
If you did not complete any of the above programs, Explain:
Part 4 - PERSONAL ISSUES Please note: Marking a “Yes� box will not automatically disqualify you. However, misrepresentation of information may result in immediate disqualification or expulsion. Yes Have you used illegal drugs in the past 2 years? Have you abused alcohol in the past 2 years? Have you ever been arrested? Have you ever been convicted of a crime or put on probation? Have you ever been pregnant or fathered a child out of wedlock? Have you ever been diagnosed with a physical or mental illness? Have you ever engaged in self-destructive behavior (suicide attempt, cutting, eating disorder etc) in the past 2 years? Have you ever been diagnosed with debilitative anxiety and/or depression? Have you ever been diagnosed with a learning disorder or studied under an IEP? Have you taken part in sex outside of marriage or adultery in the past 2 years? Have you ever been diagnosed with a physical disability? Do you have any medical concerns, are under the care of a physician for a specific problem and/or are taking any prescription medications? If you marked Yes for any of the Personal Information, please explain for each item (attach additional paper if needed): 1. the dates, duration, and details 2. any treatment received and its outcome 3. any ways in which the issue(s) will affect you while at Converge? (i.e. need for on going counseling; learning challenges, etc.)
No
Part 5 - SPIRITUAL LIFE INFORMATION Do you consider yourself to be a Christian? If Yes, describe why?
Yes
No
For how long?
yrs
How would you describe yourself as you consider participating in Converge? (check all that apply) ___ I am a new Christian and want to grow in the Lord ___ I am in a transition time of my life and want to seek God and pray. ___ I need revival in my walk with God and hope this program will restore my faith. ___ I am passionate about serving Jesus and want to spend this time learning to love Him more. ___ Other (please describe):
Part 6 – Giftings and Talents What are some of your giftings and talents? ___ Musician Which instrument(s) do you play? ___ Art Which media or form of expression? ___ Vocalist
___ Intercession
___ Sound Technician
___ Evangelism
___ Prayer Leading
___ Prophetic
___ Worship Leading
___ Other (please describe):
How did you originally find out about Converge? _____Web site
How did you find our site?
_____Word of Mouth
Name/relationship to you:
_____Conference
Name of Conference and Location:
_____Other
Please Specify:
I declare all information given in this document to be true and accurate as of this date. ____________________________________ Signature
________________ Date
Please return this form to: Bethany International Attn: Converge
mths
6820 Auto Club Road, Suite C, Bloomington, MN 55438 Fax: 952-829-2535
Phone: 800-323-3417
Email: converge@bcom.org