Kathi Small

December 21st, 2017

Kathi Small

December 21st, 2017

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Let’s Talk!
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Internship (8-15 weeks)
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Short-Term Team Participant Form
PARTICIPANT INFORMATION (completed by participant or authorized guardian)
Please indicate the organization or team name of the team you will be participating with:*
Participant Name (as it appears on passport)*
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Address*
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Passport Expiration Date*
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Passport expiration is at least 6 months after final date of travel?*

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Please note that if your Passport is expiring within 6 months of the final trip date, you will need to renew your passport prior to the trip.
Date of Birth*
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T-Shirt Size*

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Do you have any physical conditions that might require special accommodations or on this trip? If yes, please explain*
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Do you have any known allergies? If yes, please list below*
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Known Allergies
Are you currently taking any prescription medications? If yes, please list below.*
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Prescription medications list
Do you have any dietary restrictions? If yes, please explain.*
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Dietary restrictions
EMERGENCY CONTACT
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If you are under 18 years, please type the email of a parent and/or guardian.
PHOTO RELEASE
I give South America Mission permission to use my likeness in photographs, video recordings, and other digital media in any and all of its publications, including print publications, websites, and social media platforms, without payment or other consideration.*
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South America Mission is privileged to carry out Christian ministry that results in “redeemed lives, beautiful churches, and transformed communities.” Towards that end, we are continually developing a staff team of competence, character, and commitment to serving others. We desire to have a team that joyfully works together with passion for our mission. Thank you for your interest in being part of our team and taking this first step of exploration with South America Mission.
BASIC INFORMATION
Full Legal Name*
First Middle Last
Address*
Street Address City State ZIP Code

Phone*
Email*

WORK INTEREST
Role(s) Interested In*
Employment Desired*

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Available Start Date*
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Desired Annual Salary*
Do you know anyone who has been or is still employed by our organization? If yes, please list name(s):*
Why are you interested in working with South America Mission?*
Have you read, and do you agree with Our Beliefs?*

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EDUCATION
Please list up to three post-secondary education experiences, starting with the most recent. This may include college, university, seminary, or formal training programs.
Did you earn a high school diploma or equivalent (GED)?*

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1. College, University or Training Program Name
Location
Degree or Program
Field of Study
Graduated?

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In Progress
2. College, University or Training Program Name
Location
Degree or Program
Field of Study
Graduated?

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In Progress
3. College, University or Training Program Name
Location
Degree or Program
Field of Study
Graduated?

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In Progress
EMPLOYMENT HISTORY
Please list up to 3 previous employers, starting with your most recent.
Employer Name*
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End Date
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Supervisor’s Name & Title*
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Employer Name
Job Title
Start Date
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End Date
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Responsibilities / Achievements
Reason for leaving
Supervisor’s Name & Title
May we contact him/her?
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Work Phone
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Employer Name
Job Title
Start Date
MM slash DD slash YYYY

End Date
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Responsibilities / Achievements
Reason for leaving
Supervisor’s Name & Title
May we contact him/her?
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Work Phone
Email

LANGUAGES
Please describe any languages you speak and your level of fluency.
FAITH AND PASSIONS
Current Church You Attend*
City, State*
How long have you attended this church?*
What is / has been your church involvement?*
Provide us with the name and contact information of a pastor or spiritual mentor who can speak to your Christian character.*
This section is reserved for you to speak into your faith, passions, and additional skills that you would like to share.
RESUME & COVER LETTER
Please upload a current resume (PDF).*
Max. file size: 50 MB.

Please upload a cover letter (PDF).*
Max. file size: 50 MB.

APPLICANT INFORMATION
Do you identify as a protected veteran?
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No
I prefer not to answer.
Have you ever been convicted of a felony?
Yes
No
If yes, please kindly explain:
Have you ever been asked to resign or been terminated from a previous job?
Yes
No
If yes, please kindly explain:
Have you ever been convicted of child abuse, sexual abuse, or any crime involving harm to a minor?
Yes
No
If yes, please kindly explain:
South America Mission is both an equal opportunity employer and a faith-based religious organization. We conduct hiring without regard to race, color, ancestry, national origin, citizenship, age, sex, marital status, parental status, membership in any labor organization, political ideology, or disability of an otherwise qualified individual. The status of South America Mission as an Equal Opportunity Employer does not prevent the organization from hiring personnel based on their religious beliefs so that all personnel share the same religious commitment. Pursuant to the Civil Rights Act of 1964, Section 702 (42 U.S.C. [§] 2000e[- ]1(a)), South America Mission has the right to hire only candidates who whole-heartedly and without reservation agree with South America Mission's Beliefs.
SIGNATURE
Consent*
I certify that the statements made in this application are true.*
Consent*
I authorize South America Mission to seek information from the references sources and employers listed on this application.*
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