PERSONAL INFORMATION Today’s Date: ______
Full Name______SS# ______
Birthdate ______-______Age (as of this May) ______Gender: M_____ F_____
Current Address ______
City, State, Zip ______Home Phone ( ) ______
Work/School Phone: ( ) ______Email______
Permanent Address: (if different from above)
______
High School/ College Currently Attending ______
Grade/ Classification in School ______
Church ______City, State ______
Pastor ______
Describe your level of involvement in your church. (attendance, small group, ministry)
______
______
If you are away from home (in college, etc.) and have another church home, please list it here:
Church ______City, State ______
Pastor ______
EMPLOYMENT HISTORY
List your last three jobs, starting with the most recent.
Dates of employment ______Job Title ______
Main responsibilities______
Employer ______Phone ______
Dates of employment ______Job Title ______
Main responsibilities______
Employer ______Phone ______
Dates of employment ______Job Title ______
Main responsibilities______
Employer ______Phone ______
Have you ever been fired from a job? If yes, please explain further: ______
VOLUNTEER EXPERIENCE
1. List any experience you have had as a volunteer with religious, civic, and/or scholastic organizations.
2. Do any of these volunteer experiences relate specifically to your desire to be a LifeSpring intern?
3. Have you ever been an intern for any other organization?
4. If you have had other experiences that you feel relate to your desire to do an internship, please list them here:
CHARACTER REFERENCES
1. Your Pastor______Phone ______
2. Teacher/Professor ______Phone ______
3. Other ______Phone ______
As a part of your application process, you need to get two of the people listed above to fill out character reference forms, and send them to: LifeSpring Community Health, 2507 McCallie Ave Chattanooga, TN 37404.
ADDITIONAL QUESTIONS
1. Have you ever been convicted of a crime as a juvenile or as an adult? If yes, please explain.
2. Have you ever been convicted or implicated in any situation involving physical or sexual abuse of another person? If yes, please explain.
DOCTRINAL BELIEFS
Read carefully and circle your response. Use extra room for comments if needed.
1. Do you believe that the Bible, both Old and New Testaments, is the Word of God, and does its truth have authority in your life? Yes No
2. Do you believe that Jesus Christ is the Son of God, and does his Lordship rule over all things, including all things in your life? Yes No
3. Do you believe that Jesus Christ historically died on the cross and that the blood he shed takes away your sins and makes you righteous before God? Yes No
4. Do you believe that Jesus is Savior of sinners and that men and women need to be converted through our preaching of the gospel of grace to them? Yes No
5. Do you believe that the church is the body of Christ, and that as a member of it you have been gifted to serve God’s people, and are you committed to this purpose? Yes No
I have read all of the above questions and answered them as truthfully as I am able.
Signature______Date ______
PERSONAL QUESTIONS
For the following questions, please answer in short paragraphs. Respond as completely as you are able.
1. How did you come to know Jesus Christ as your personal Savior?
2. Briefly describe you understanding of who God is, who Christ is, and what a Christian is.
3. Describe what is going on in your walk with Jesus.
4. Why do you believe God is calling you into this internship? What do you hope to learn through the experience?
5. What are your expectations of LifeSpring in the internship?
6. Have you had any other experiences in a multicultural work, ministry, and/or worship environment? If yes, describe. If no, please share some of your thoughts and how you are going to deal with this element of the internship.
LifeSpring Community Health
Agreement Regarding Confidentiality
Those associated with LifeSpring Community Health, either as students, interpreters, observers, etc., must be continuously mindful of the special nature of the business of this organization. Seeking health care services is a highly private and personal matter. Further, such services can be effectively rendered only in a climate of respect and trust. Hence, all information which LifeSpring staff or others associated with LifeSpring Community Health possess any individual who receives professional services at LifeSpring Community Health, including the mere fact that the individual is a client, is considered strictly confidential. Under special circumstances such information may be divulged to outside parties, but only by designated staff. Conversations about clients at the workplace should be for business purposes only and should take place in areas where there is the requisite privacy. Conversations which occur outside LifeSpring’s premises must never include reference to specific clients. Any breech of the rule of the confidentiality of client information is grounds for immediate termination.
It is the policy of the organization to provide its clients with the best possible service. Associat4es are expected to treat clients in a courteous and respectful manner at all times. Associates must always remember that the client is entitled to the same thoughtful treatment that an associate would like to receive. Clients should not be treated in a condescending or impolite manner and should not be kept waiting an unreasonable amount of time.
I have read the above statement concerning confidentiality and agree to abide by it.
Signature