Internship Application

Internship Application

Personal Information

Full Name:
Last / First / M.I.
Address:
Street Address / Apartment/Unit #
City / State / ZIP Code
Home Phone: / ( ) / Cell Phone: / ( )
E-mail Address:
Occupation and Employer Name:
Birth Date: / Place of Birth:
Citizenship: / Passport Number:

Health History

Health Problems: / Allergies:
Physical Limitations:
Medications being taken:

Emergency Contact Information

Please list the person you would want contacted in case of emergency
Full Name:
Last / First / M.I.
Address:
Street Address / Apartment/Unit #
City / State / ZIP Code
Primary Phone: / ( ) / Alternate Phone: / ( )
Relationship:

References

Local Church Affiliation: / Phone Number: / ( )
Contact Name: / Are you a member?
Relationship: / E-mail Address:
Name of Reference: / Phone Number: / ( )
Relationship: / E-mail Address:
Name of Reference: / Phone Number: / ( )
Relationship: / E-mail Address:

Please include one employer or professor/department advisor and one peer.

Internship Application Page 2

Education

High School:
Name / City and State / Years Attended
College:
Name / City and State / Years Attended
Name / City and State / Years Attended
Major Subjects: / Degrees Completed:
Will you be seeking school credit for this internship?
If so, Contact Name: / Phone Number: / ( )
Earliest Travel Date: / Return Date:

Work History

Please list your current and previous employment experiences.
Company/Employer #1: / Position:
Dates of Employment: / Phone Number: / ( )
Company/Employer #2: / Position:
Dates of Employment: / Phone Number: / ( )

Skills and Experiences

Have you been on a mission trip before? / If so, where?
Languages you speak other than English:
List your talents, hobbies, abilities and gifts:
List any overseas or cross-cultural experiences:
List any previous positions and experience working in underdeveloped communities:

Please answer the following questions (If online, type right after the questions; otherwise, write on a separate page)

1.  How did you come to know Jesus Christ as your personal Savior?

2.  How is your relationship with Christ currently being developed?

3.  What is an experience that has marked your life?

4.  What are your prayer requests concerning your involvement with this mission project?

5.  How has God been leading and preparing you for this internship? What is your present involvement with organizations or issues of social justice, poverty, reconciliation, etc? Do you financially support these?

Mail completed form to Breakthrough Partners, 110 Third Ave. N, Ste. 101 Edmonds, WA 98020 or