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Application ~
Basic
Information ~
Contact
Copy and paste this application to a word
processor and print it out. The red lines indicate a need
to begin a new page in the word processor.
Mail you completed application to: Mission Experience
2009
Victory Lutheran Brethren Church
510 9th Ave. S.W.
Jamestown, ND 58401
Please also have your references return his
or her recommendation to the same address. Thanks!
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Victory Lutheran Brethren Church
Summer Mission Experience 2009 Application
Return to:
Victory Lutheran Brethren Church
Attn: Summer Mission Experience
510 9th Ave. S.W.
Jamestown, ND 58401
Name: ___________________________________________ Age:
_______
Date of Birth: _____/_____/_______ Sex: M / F
Address:
_______________________________________________________________
Phone: ______ - ______ -_________
E-mail address:
___________________________________________________________
Name of parent or guardian:
________________________________________________
Person to be notified in an emergency 1:
________________________________________
Relationship: ______ Phone: ______ - ______ -________
Phone: ______ - ______ -________
Person to be notified in an emergency 2:
________________________________________
Relationship: ______ Phone: ______ - ______ -________
Phone: ______ - ______ -________
What church do you attend?_______________________________
Current Grade:_____
Are you covered by health and accident insurance? Y / N
With whom?
____________________________________________________________
Policy number: ____________________________________
If accepted to serve, what’s your T-shirt size? XS - S - M -
L - XL - XXL - XXXL
List all current and previous work experience. Also include
Employer's Name,
Address, Phone #, Supervisor, Position, Dates employed, and
Reason for leaving
Please answer the following questions.
Describe any experience you have working with children.
Why do you desire to participate in this experience?
What do you think are your greatest strengths?
How did you become a Christian? Also, what has God been
teaching you recently.
How would you describe salvation to a child? What Bible
verses would you use?
List any musical instruments you play or talents that God
has given you.
REFERENCES: Send out the attached reference forms. List
below the people you are sending them to. When you send the
forms, be sure to put your name on each sheet. Provide a
stamped envelope address to Victory Lutheran Brethren
Church. References must be to Victory as soon as possible.
All three references are required before an application can
be completely processed.
Name, Position, Daytime Phone #
1) Your Pastor or Youth Worker
________________________________________________________________________
2) Recent Employer or a Teacher
________________________________________________________________________
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Release Form:
I understand that if I am accepted as a volunteer and if any
statement herein is not true, I may be released immediately.
I understand that if accepted, I will be required to abide
by all church policies, standards and regulation, as they
are promulgated from time to time.
I hereby authorize Victory to contact all prior employers
and references listed herein to verify all information
provided and to obtain any and all information related to my
character and past work performance. I further herby release
all references and prior employers from any liability for
information provided in good faith.
I affirm that I have neither been convicted of, nor am I the
subject of pending charges for, any offense involving actual
or attempted child abuse of sexual molestation in any
jurisdiction.
I hereby affirm and acknowledge, by signing immediately
below, that all of the information provided and all of my
answers to the foregoing questions are true and complete,
and that any misrepresentations or omissions may be grounds
for rejection or, if later accepted, dismissal.
______________________________________________
__________________
Applicant’s Signature Date
______________________________________________
__________________
Parent/Guardian Signature (if under 18) Date
If you have any questions contact:
Youth Pastor Luke Fiskness
Victory Lutheran Brethren Church
510 9th Ave. S.W.
Jamestown, ND 58401
Phone: 701-251-1570 or 701-320-1538
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REFERENCE FORM #1 (Youth Leader, Pastor, Small Group
Leader)
Victory Lutheran Brethren Church
Summer Mission Experience
2009 Application
Reference Form #1
Return to:
Luke Fiskness
Victory Lutheran Brethren Church
510 9th Ave SW
Jamestown, ND 58401
Applicant’s
name:_________________________________________________________
The above named person is applying for a short term mission
opportunity at Victory Lutheran Brethren Church. The
information requested will supplement that provided by
personal interview. It is of great importance for us to
obtain objective and valid statements form persons who have
some personal knowledge of the applicant’s ability and
characteristics. This applicant has agreed to release all
references from an liability for information provided in
good faith.
The early return of this form will be appreciated as it will
expedite the processing of this candidate’s application. Any
information which you may give us will be regarded as
strictly confidential. Please send this form directly to
Victory Lutheran Brethren Church.
Your name:____________________________________ Phone # ____
- ____ - _______
Address:________________________________________________________________
Position/Organization:_____________________________________________________
How long have you known the applicant?__________ In what
capacity? _____________
Is the applicant a Christian?_________________ If known, for
how long?____________
Does the applicant appear to be growing in his/her Christian
experience?_____________ Please explain:
Does the applicant take an active interest in Christian
service?_____________ Please explain:
Have you seen the applicant in response to understanding the
Bible, witnessing, and prayer life?
Please grade the applicant on the following characteristics
and traits. Use “1” to indicate superior. “2” for above
average, “3” if average, and “4” if weak in that area.
Please evaluate the applicant in relationship to his/her own
age group.
____ Tact ____ Sense of humor ____ Willingness
____ Dependability ____ Initiative ____ Attitude towards
authority
____ Judgment ____ Courtesy ____ Attitude towards hard work
____ Punctuality ____ Initial impression ____ Public
speaking ability
____ Honesty ____ Personal integrity ____ Ability to make
friends
Please indicate on a scale of 1-10 (1 being worst, ten being
best) you perception of the applicant in these areas.
Able to follow instruction = 1 - 2 - 3 - 4 - 5 - 6 - 7
- 8 - 9 - 10
Loyal
= 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
Outgoing and friendly = 1 - 2 - 3 - 4 - 5 - 6 - 7
- 8 - 9 - 10
Able to lead
others
= 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
Consistent in Christian walk = 1 - 2 - 3 - 4 - 5 - 6 - 7 -
8 - 9 - 10
Disciplined
= 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
Enthusiastic
= 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
Able to
adjust
= 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
Abel to cope with problems = 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8
- 9 - 10
Team
player
= 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
Easily
offended
= 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
Inclined to
criticize
= 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
Moody
= 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
During the course of a the week, this applicant will be in
daily contact with children, and in a teaching/counseling
position. Would you consider the applicant qualified for
such a position? Yes or No
Please circle your choice of recommendation:
Strongly recommend ~ Recommend with some reservation ~
Recommend ~ Do not recommend
Signature:_________________________________________
Date:____________
Thank you for your assistance!
Victory Lutheran Brethren Church
Summer Mission Experience
2009 Application
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REFERENCE FORM #2 (Teacher
or Employer)
Victory Lutheran Brethren Church
Summer Mission Experience
2009 Application
Reference Form #1
Return to:
Youth Pastor Luke Fiskness
Victory Lutheran Brethren Church
510 9th Ave SW
Jamestown, ND 58401
Applicant’s
name:_________________________________________________________
The above named person is applying for a short term mission
opportunity at Victory Lutheran Brethren Church. The
information requested will supplement that provided by
personal interview. It is of great importance for us to
obtain objective and valid statements form persons who have
some personal knowledge of the applicant’s ability and
characteristics. This applicant has agreed to release all
references from an liability for information provided in
good faith.
The early return of this form will be appreciated as it will
expedite the processing of this candidate’s application. Any
information which you may give us will be regarded as
strictly confidential. Please send this form directly to
Victory Lutheran Brethren Church.
Your name:____________________________________ Phone # ____
- ____ - _______
Address:________________________________________________________________
Position/Organization:_____________________________________________________
How long have you known the applicant?__________ In what
capacity? _____________
Is the applicant a Christian?_________________ If known, for
how long?____________
Does the applicant appear to be growing in his/her Christian
experience?_____________ Please explain:
Does the applicant take an active interest in Christian
service?_____________ Please explain:
Have you seen the applicant in response to understanding the
Bible, witnessing, and prayer life?
Please grade the applicant on the following characteristics
and traits. Use “1” to indicate superior. “2” for above
average, “3” if average, and “4” if weak in that area.
Please evaluate the applicant in relationship to his/her own
age group.
____ Tact ____ Sense of humor ____ Willingness
____ Dependability ____ Initiative ____ Attitude towards
authority
____ Judgment ____ Courtesy ____ Attitude towards hard work
____ Punctuality ____ Initial impression ____ Public
speaking ability
____ Honesty ____ Personal integrity ____ Ability to make
friends
Please indicate on a scale of 1-10 (1 being worst, ten being
best) you perception of the applicant in these areas.
Able to follow instruction = 1 - 2 - 3 - 4 - 5 - 6 - 7
- 8 - 9 - 10
Loyal
= 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
Outgoing and friendly = 1 - 2 - 3 - 4 - 5 - 6 - 7
- 8 - 9 - 10
Able to lead
others
= 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
Disciplined
= 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
Enthusiastic
= 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
Able to
adjust
= 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
Abel to cope with problems = 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 -
9 - 10
Team
player
= 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
Easily
offended
= 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
Inclined to
criticize
= 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
Moody
= 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10
During the course of a the week, this applicant will be in
daily contact with children, and in a teaching/counseling
position. Would you consider the applicant qualified for
such a position? Yes no
Please circle your choice of recommendation:
Strongly recommend ~ Recommend with some reservation ~
Recommend ~ Do not recommend
Signature:_________________________________________
Date:____________
Thank you for your assistance!
~Pastor Luke
Victory Lutheran Brethren Church
Summer Mission Experience
2009 Application
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