Student Application Anthem School of Ministry Living Water • Olympia, WA
1.
Name: (last) ____________________________________ (first) ________________________
2.
Home Address: (street) _________________________________________________________ (city) ______________________________ (state) _________________ (zip) _____________
3.
Phone Numbers: (home) (_______)_________________ (cell) (_______)_________________
4.
Email: ______________________________________________________________________
5.
Current Age: __________
7.
* Driver’s License Number (a valid driver’s license is required for the duration of Anthem).
6.
Birthday: ______/______/______
License Number: ____________________ State of Issue: ____________ Exp Date: _______ 8.
* Social Security Number: ______________________________________
9.
* Passport Number and full legal name as it appears on your passport (a valid passport is required for the duration of Anthem). Passport Number: ____________________; Exp Date: _______ Name on Passport: ____________________________________________________________
10.
Father’s / Guardian’s Name: _____________________________________________________
11.
Mother’s / Guardian’s Name: _____________________________________________________
12.
Of what country are you a citizen? ________________________________________________
13.
Church Name: ______________________________ City& State: _______________________ Phone: (_______)_________________ Pastor’s Name: ________________________________
14. Which of the following areas of ministry do you enjoy or find that you have gifting? (Please check all that apply.) Speaking Teaching Music Worship Art Drama
Dance Evangelism Counseling Administration Encourager Hospitality
Children’s work Youth work Prayer Electrical Plumbing Carpentry
Medical Computers Secretarial Graphics Video Other:
* Items 7, 8 and 9 will be needed by the start date of Anthem, but are not needed for the initial application.
Educational & Academic History Note: a minimum of a GED is required prior to admittance into Anthem. 15.
Year of your high school graduation: ______________
16.
How many years of college will you have completed prior to entering Anthem? _____________
17.
Describe your academic strengths and weaknesses: __________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
Personal History 18.
When did you receive Jesus Christ as your personal savior? ____________________________
19.
Briefly describe your lifestyle before your salvation: ___________________________________ ____________________________________________________________________________ ____________________________________________________________________________
20.
Have you been baptized in water? If so, when? ______________________________________
21.
Have you been baptized with the Holy Spirit? If so, when? _____________________________
22.
Please write the story of how you met Jesus in one hundred words or less: ________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
______________________________________________________________________ 23.
List your reasons for wanting to join Anthem: ________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
24.
What calling do you believe God has placed upon your life (schooling, ministry, occupation, etc.)? ____________________________________________________________________________ ____________________________________________________________________________
______________________________________________________________________
25.
How do your parents/guardians feel about you joining Anthem? ____________________________________________________________________________ ____________________________________________________________________________
26.
How many brothers and sisters do you have? _______________________________________
27.
Describe your involvement at your church (your attendance, and any serving, ministry, teaching, etc.): ________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
28.
Are you planning on participating in Anthem for one or more years? ______________
29.
What are your plans after Anthem? _______________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
30.
Please describe your devotional life (time devoted to prayer and Bible reading) over the past three months: ________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
31.
Please describe any conditions you have (or have had in the past two years) that affect your relationships, ability to study, or other areas of life (depression, anxiety attacks, learning disability, attention deficit disorder, etc.): ____________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
32.
During the past six-months have you engaged in behaviors that are inconsistent with the life of a believer (drunkenness, drug use, sexual activity, viewing pornography, lying, cheating, etc.)? If yes, please describe: ___________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
33.
Will it be difficult for you to respond to the authority of Anthem staff or Living Water staff? ________________________________________________________________
Anthem-wear Information Men:
Neck Size (inches): _______ Arm Length (inches: ________ T-shirt size: _________
Women:
Dress shirt size: _________ T-shirt size: __________
NOTE: All anthem students are required to have the following items of clothing to wear for special events during the Anthem year: Khaki casual pants (Dockers), Black dress pants, White long-sleeved collared dress shirt, Black socks, Plain Black T-shirts, Black closed-toed shoes.
Financial Information Please indicate how you are planning to pay for your involvement in Anthem: _____________________ ___________________________________________________________________________________ ___________________________________________________________________________________
Student Agreement I have read the current Anthem Student Handbook, and I agree to fully comply with all program rules, guidelines and policies, including those related to dismissal, romantic relationships, living in dorm-style housing, and my personal financial commitment to Anthem. I understand that my compliance with these rules, guidelines and policies applies to me during the entire time I am an Anthem student, including weekends, scheduled breaks, times of travel, and missions trips. (circle one) YES / NO All information provided in this Application is complete and accurate. I realize that supplying incomplete or false information in this Application, or during my interview with Anthem Staff, may result in my failure to be accepted into Anthem, or may result in being dismissed from the program. I consent to the sharing of my personal information (from the application process and during my time as an Anthem student) with the Anthem staff, the Church of Living Water staff, and with any Host-Parents with whom I might be placed. _____________________________________________
___________________
Applicant’s Signature
Date
Submission of Application Applications must be postmarked six weeks prior to the program start date of Anthem. Any faxed copies must be followed up immediately by mailing the original Application. Please send your completed application along with other required information to:
Anthem 1615 Chambers St. SE Olympia, WA 98501
Section for Foreign Students A valid visa and passport from is required for the duration of Anthem. You must bring the papers associated with your visa and your passport with you to Anthem. Please contact us for a separate guide to help you attain the proper clearance for your participation in Anthem. a.
Type of Visa: ____________________
b.
Dates Visa is Effective: ____________
c.
Type of Passport: _________________
d.
Dates Passport is Valid: ___________
e.
Will your Visa need to be renewed during your time in Anthem? _______
f.
Will your Passport need to be renewed during your time in Anthem? _______
g.
LIN Number: # _________________________
h.
Name of U.S. Consulate or Embassy which issued your Visa and the city and country in which it is located: ______________________________________________
Application Checklist _____ Non-refundable $50 application fee, made out to Anthem _____ Completed application _____ Two confidential references from Christian friends _____ Confidential reference from your Pastor _____ Recent photograph (graduation or passport style) _____ Completed health care information form _____ Photocopy of current immunization record _____ Photocopy of current driver’s license and proof of insurance _____ Completed interview with Anthem staff member _____ Criminal background check (to be completed prior to the program start date)
For Minor Applicants Only An additional parental/guardian release form is available from the Anthem Office and can be requested for any students who will not yet be 18-years-old by the program start date. This form is NOT required to be turned in with this initial application, but must be submitted by the program start date. _____ Parental/guardian release form
Anthem Health Care Information Please fill out the following information as thoroughly and accurately as possible: Student’s Last Name
First
Date of Birth
Middle
Insurance Company
Current Age
Insurance Policy Number
Address
Insurance Company Phone Number
City
State
Zip
Father’s Name
Home Phone Number
Father’s Emergency Phone Number
Allergies (drugs, food, other)
Mother’s Name
Medications you are currently taking
Mother’s Emergency Phone Number
Last Tetanus Immunization Family Physician
Physician’s Phone Number
Emergency Contact (non family member)
Emergency Contact Phone Numbers
Please list all conditions you have that require a doctor’s supervision:
Please list any physical conditions that that are occasionally bothersome to you (back problems, headaches, etc.):
Please note any other pertinent health care information or requests:
Dates of Immunizations Hepatitis A:
Smallpox:
B:
Tetanus:
Polio:
Meningitis
DTP:
MMR:
TB Test:
This health care information is complete and accurate. I understand it is my responsibility to update this form in a timely manner should any information change before I complete my time in Anthem. Student’s Signature:
Date:
Friend’s Confidential Reference Anthem School of Ministry Living Water • Olympia, WA
Applicant’s Name: _____________________________ Phone Number: (_______)_______________ Applicant’s Instructions: This form is to be filled out and mailed directly to Anthem by a Christian friend. Family members or other relatives may not fill out this form. Friend’s Instructions: The individual named above has applied to become a student in the Anthem program. Anthem is a nine-month, intense, church-based, leadership training school for young adults who desire to grow in their knowledge of the Bible and in their ability to minister effectively. Serious consideration will be given to your comments, so carefully complete this form and return it directly to Anthem as quickly as possible. Your comments will be held in confidence. Any additional comments may be made on a separate sheet of paper and attached to this reference.
1.
Please check the box that best describes the applicant: Excellent
Mental ability Personal motivation Maturity Appearance Church attendance / involvement Spiritual growth observed Self-image Emotional stability Coping with personal problems Response to pressure Financial responsibility Honesty Openness / transparency Moral standards Positive attitude Judgment / common sense Creativity Adaptability / flexibility Teamwork / cooperation Servanthood Follows instructions Teachable Liked by others Concern for others Communication skills Leadership ability Self-discipline Physical condition of health
Good
Fair
Poor
No Observation
2.
In your opinion, this applicant’s Christian witness is which of the following: Mature Over-emotional
3.
Contagious
Genuine and growing
Superficial
Other:
Please comment on areas of strength or weakness in the character of the applicant? _________ ______________________________________________________________________________
4.
What specific gifts or abilities do you recognize in this applicant? _________________________ ______________________________________________________________________________
5. Does this applicant have any persistent problems or habits that might restrict him/her from fitting into an intense and challenging program? If so, please describe. _____________________________ ______________________________________________________________________________ 6. To your knowledge, during the past six-months has the applicant engaged in behaviors that are inconsistent with the life of a believer (drunkenness, drug use, sexual activity, viewing pornography, lying, cheating, etc.)? If yes, please describe: _________________________________________ ______________________________________________________________________________ 7. Would you recommend this applicant for acceptance into Anthem? Yes 8.
No
With hesitation
How many years have you known the applicant? ___________ years. How close do you consider your relationship to be? Very close
Fairly close
An acquaintance
Minimal
Applicant’s Name Referent’s Name Address City
State
Zip
Phone ( )
Referent’s Home Church Position in Church (if applicable) Signature Please mail to: Anthem 1615 Chambers St SE Olympia, WA 98501
Date
Phone: Fax: Email:
(360) 754.0419 (360) 786.1464
[email protected]
Friend’s Confidential Reference Anthem School of Ministry Living Water • Olympia, WA
Applicant’s Name: _____________________________ Phone Number: (_______)_______________ Applicant’s Instructions: This form is to be filled out and mailed directly to Anthem by a Christian friend. Family members or other relatives may not fill out this form. Friend’s Instructions: The individual named above has applied to become a student in the Anthem program. Anthem is a nine-month, intense, church-based, leadership training school for young adults who desire to grow in their knowledge of the Bible and in their ability to minister effectively. Serious consideration will be given to your comments, so carefully complete this form and return it directly to Anthem as quickly as possible. Your comments will be held in confidence. Any additional comments may be made on a separate sheet of paper and attached to this reference.
1.
Please check the box that best describes the applicant: Excellent
Mental ability Personal motivation Maturity Appearance Church attendance / involvement Spiritual growth observed Self-image Emotional stability Coping with personal problems Response to pressure Financial responsibility Honesty Openness / transparency Moral standards Positive attitude Judgment / common sense Creativity Adaptability / flexibility Teamwork / cooperation Servanthood Follows instructions Teachable Liked by others Concern for others Communication skills Leadership ability Self-discipline Physical condition of health
Good
Fair
Poor
No Observation
2.
In your opinion, this applicant’s Christian witness is which of the following: Mature Over-emotional
3.
Contagious
Genuine and growing
Superficial
Other:
Please comment on areas of strength or weakness in the character of the applicant? _________ ______________________________________________________________________________
4.
What specific gifts or abilities do you recognize in this applicant? _________________________ ______________________________________________________________________________
5. Does this applicant have any persistent problems or habits that might restrict him/her from fitting into an intense and challenging program? If so, please describe. _____________________________ ______________________________________________________________________________ 6. To your knowledge, during the past six-months has the applicant engaged in behaviors that are inconsistent with the life of a believer (drunkenness, drug use, sexual activity, viewing pornography, lying, cheating, etc.)? If yes, please describe: _________________________________________ ______________________________________________________________________________ 7. Would you recommend this applicant for acceptance into Anthem? Yes 8.
No
With hesitation
How many years have you known the applicant? ___________ years. How close do you consider your relationship to be? Very close
Fairly close
An acquaintance
Minimal
Applicant’s Name Referent’s Name Address City
State
Zip
Phone ( )
Referent’s Home Church Position in Church (if applicable) Signature Please mail to: Anthem 1615 Chambers St SE Olympia, WA 98501
Date
Phone: Fax: Email:
(360) 754.0419 (360) 786.1464
[email protected]
Pastor’s Confidential Reference Anthem School of Ministry Living Water • Olympia, WA
Applicant’s Name: _______________________________ Phone Number: (______)______________ Applicant’s Instructions: This reference should be completed and mailed directly to Anthem by your pastor. If your father or mother is your pastor, please give this form to the assistant pastor or youth pastor in your church who knows you best. If a person other than your pastor (assistant pastor or youth pastor) completes the form, an explanation should be provided. Pastor’s Instructions: The applicant named below has applied to become a student in Anthem at the Church of Living Water. The information requested on this form will assist us in evaluating the applicant’s ability to succeed in this intense training program. Serious consideration will be given to your comments, so carefully complete this form and return it directly to Anthem as quickly as possible. This reference will be kept in confidence. Thank you for your assistance.
1.
How long have you known the applicant? ____________________________________________
2.
How long has the applicant attended your church? ____________________________________
3.
How well do you know the applicant? Very well Fairly well
Casually
By name/sight
4.
How would you describe the level of commitment shown by the applicant? Highly committed Somewhat committed Low level of commitment
5.
Evaluation of applicant’s emotional maturity (please check one): Outstandingly mature. Has demonstrated an ability to function effectively under stress. More mature and emotionally stable than average. Possesses adequate emotional stability and maturity. Has demonstrated some inability to function effectively under stress. Has frequently demonstrated signs of inability to cope with stress, such as anger or withdrawal.
6.
How does the applicant usually react in stressful, difficult situations (check all that apply)? Withdraws Gets discouraged Gets angry Accepts patiently Acts constructively
7.
Seeks assistance from leaders
Has applicant proven on any occasion to be unreliable, dishonest, or of questionable character? No Yes If yes, please explain: ________________________________ ___________________________________________________________________________ ___________________________________________________________________________
8.
As far as you know, has the applicant ever been arrested for any offense? No Yes If yes, please explain: _______________________________ ___________________________________________________________________________
9.
Please check the box that best describes the applicant: Excellent
Good
Fair
Poor
No Observation
Mental ability Personal motivation Maturity Appearance Church attendance / involvement Spiritual growth observed Self-image Emotional stability Coping with personal problems Response to pressure Financial responsibility Honesty Openness / transparency Moral standards Positive attitude Judgment / common sense Creativity Adaptability / flexibility Teamwork / cooperation Servanthood Follows instructions Teachable Liked by others Concern for others Communication skills Leadership ability Self-discipline Physical condition of health 10.
In your opinion, in which of the following areas of ministry does the applicant seem gifted?
Speaking Teaching Music Worship Art Drama 11.
Dance Evangelism Counseling Administration Encourager Hospitality
Children’s work Youth work Prayer Electrical Plumbing Carpentry
Medical Computers Secretarial Graphics Video Other:
If you were to consider this applicant for an intense, fast-paced and challenging discipleship program, would you feel that this applicant has the capacity and potential to succeed? Yes No If no, please explain: _______________________________________ ____________________________________________________________________________
12.
To your knowledge, during the past six-months has the applicant engaged in behaviors that are inconsistent with the life of a believer (drunkenness, drug use, sexual activity, viewing pornography, lying, cheating, etc.)? If yes, please describe: _________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
13.
Do you recommend the applicant for acceptance as a student of Anthem? Yes No With hesitation
14.
If you would like to share any additional information, please attach a separate sheet with this reference, or indicate below that you would like a phone call to discuss this reference further. Would you like a call to discuss this applicant further?
Yes
No
Name of Pastoral Referent Address City
State
Zip
Phone (
)
Church & Denomination Position in church (if applicable) Signature
Date
Please mail to: Anthem 1615 Chambers St SE Olympia, WA 98501
Phone: Fax: Email:
(360) 754.0419 (360) 786.1464
[email protected]
Check here if you would like us to send you more information about the Anthem School of Ministry at the Church of Living Water. Yes, please send me more information.
