Applicant's First Name (Exactly as it appears on Passport)
*
Applicant's Middle Name (Exactly as it appears on Passport)
*
Applicant's Last Name (Exactly as it appears on Passport)
*
Applicant's Date of Birth
*
MM
DD
YYYY
Applicant's T-Shirt Size
*
Small
Medium
Large
X Large
XX Large
Trip Applying For
*
GAP YEAR PROGRAM
Applicant's Cell Phone
*
This is the first number that Providing Purpose will call if they need to speak to you.
(###)
###
####
Applicant's Home Phone
(###)
###
####
Applicant's Permanent Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Applicant's Temporary Address (If Applicable)
Example: College student living away from home certain months
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Applicant's Marital Status
*
Single
Married
Divorced
Widowed
Applicant's School Grade/Role
*
9th
10th
11th
12th
College
Adult
Pastor/Admin
Who did you hear about us from?
Church you currently attend.
*
Reference Name
*
Can be any leader that can give you a recommendation.
First Name
Last Name
Reference Email
*
Church's Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact
*
First Name
Last Name
Emergency Contact Cell Phone
*
(###)
###
####
Emergency Contact Home Phone
(###)
###
####
Emergency Contact Work Phone
(###)
###
####
Emergency Contact Relationship to Applicant
*
Why would you like to participate on this GAP Year Program?
*
Have you participated on a mission trip before? If so, when, where, and with what organization?
Describe when you accepted Jesus Christ as your personal Savior and how that relationship impacts your daily life.
Personal Challenges
*
Personal struggles often intensify on the mission field. Even past issues can affect us unexpectedly. Please honestly answer the questions below to ensure that the trip you have selected is the best match for you. Please explain any of the questions where you have answered past or present in the comments box below.
Have you ever used alcohol, tobacco or illegal drugs / Abused prescription medication?
*
Never
Past
Present
Have you ever been expelled from school, arrested, convicted of a crime or served time?
*
Never
Past
Present
Have you ever received treatment from a mental health professional or pastoral counselor?
*
Never
Past
Present
Have you ever been involved in a sexual relationship outside of marriage (as defined in Genesis 2:18-24)?
*
Never
Past
Present
Have you ever struggled with an addiction?
*
Never
Past
Present
Have you ever struggled with a self-harming behavior (eating disorder, cutting, suicide, etc.)
*
Never
Past
Present
Have you ever struggled with depression or an anxiety disorder?
*
Never
Past
Present
Are you dating anyone who is also applying to this trip? If so, who?
Are you bringing your spouse or children on this trip with you? If so, please list names and ages.
The GAP Year program will involve rigorous activity in outdoor environments. Participants may not have continuous access to electricity or refrigeration.We realize some of our trips may not be suited for people with certain physical limitations or medical conditions.
Please Explain
Do you presently have any of the following conditions?
*
Check all that apply.
Have you ever been treated by a doctor or counselor for any of the following?
*
Check all that apply.
Please explain
*
Have you had surgery or been hospitalized in the last 5 years?
*
Yes
No
Are you presently under a physician's care?
*
Yes
No
Reason (illness/injury) for surgery or hospitalization or reason you are under a physician's care and for what condition.
Do you have any MEDICALLY NECESSARY dietary restrictions?
*
Do not include voluntary lifestyle choices such as vegetarian, vegan, paleo, Whole30, keto, etc. Please note that RIM does not accommodate specialized dietary needs (whether medically necessary or preference) so it is your responsibility to bring adequate supplementary food.
Explanation
*
If None of the Above put Not Applicable
Have you received all standard childhood vaccinations?
Yes
No (I'm not up-to-date)
No (I do not vaccinate)
What year was your most recent Tetanus shot?
*
Please note: If you or your student received their tetanus shot as a preteen, they may need a booster. Please check with your doctor. No waivers are available for international locations.
MM
DD
YYYY
Based on your overall health and fitness, do you have any concerns about your participation on a rigorous/remote trip?
*
Yes
No
If you have concerns, please explain.
