Summer Leadership Intensive College Intern Application

Full Name *
Full Name
Date of Birth *
Date of Birth
Gender *
Phone *
Phone
Current Address *
Current Address
Background
Ex: freshman
Will you receive college credit for this internship?
Have you ever been convicted of a felony crime?
Are you currently under indictment or on probation for any crime?
Do you have a passport?
Do you have experience in any of the following?
Getting to Know You
References
Please give the following information for three references of your choice.
Pastor or Mentor
Full Name
Full Name
Phone Number
Phone Number
Teacher or Supervisor
Full Name
Full Name
Phone Number
Phone Number
Your Choice
Full Name
Full Name
Phone Number
Phone Number
Medical Information
Emergency Contact
Full Name
Full Name
Address
Address
Cell Phone Number
Cell Phone Number
Agreement
PLEASE READ THE FOLLOWING STATEMENT CAREFULLY BEFORE AGREEING: I, THE UNDERSIGNED, HEREBY AGREE TO HOLD MERCY STREET MINISTRIES AND ALL PERSONS OR ORGANIZATIONS CONNECT WITH MERCY STREET MINISTRIES HARMLESS FROM LIABILITY. I HEREBY RELEASE MERCY STREET MINISTRIES TO OBTAIN INFORMATION FROM MY REFERENCES, AND AGREE TO HOLD HARMLESS FROM LIABILITY ANY PERSON OR ORGANIZATION THAT PROVIDED INFORMATION CONCERNING ME TO MERCY STREET MINISTRIES. I UNDERSTAND THAT ALL INFORMATION GATHERED WILL BE KEPT CONFIDENTIAL. I AGREE THAT ALL INFORMATION IN THIS APPLICATION IS TRUE. I UNDERSTAND THAT THE INFORMATION COLLECTED IN THIS FORM WILL BE USED TO CONDUCT A BACKGROUND CHECK, AND I AUTHORIZE REPRESENTATIVES OF MERCY STREET MINISTRIES TO CONDUCT STATE AND FEDERAL BACKGROUND CHECKS. I AGREE TO STRIVE TO HONOR GOD THROUGH SCRIPTURE-BASED TEACHING AND CONDUCT IN THE PERFORMANCE OF ANY SERVICES ON BEHALF OF THE MINISTRY AND IN MY LIFE. I UNDERSTAND THAT THROUGHOUT MY TIME INTERNING WITH MERCY STREET MINISTRIES I WILL BE HELD ACCOUNTABLE THROUGH CONVERSATIONS WITH MERCY STREET MINISTRIES STAFF. IF IT IS FOUND THAT I AM LIVING MY LIFE CONTRARY TO SCRIPTURE I WILL BE REMOVED AS AN INTERN.
Agreement