Request edit access
Travel Study Seminar Application Form
Presbyterian Peacemaking Program
Email address *
Seminar you are applying to attend: *
NAME AND CONTACT INFORMATION
Please share your name and preferred contact information
Last Name *
Your answer
First Name *
Your answer
Name you preferred to be called
If different than first name
Your answer
Best email *
Your answer
Best phone *
Your answer
Street mailing address *
Your answer
City *
Your answer
State *
Your answer
Zip code *
Your answer
CHURCH AFFILIATION
Denominational affiliation *
Your answer
Congregation or worshipping community affiliation *
Please share the name, city and state of the congregation or worshipping community you attend
Your answer
Mid-Council / Presbytery *
Your answer
Roles held in faith community *
(check all that apply)
Required
OTHER HELPFUL INFORMATION
Occupation/Vocation *
Please briefly describe your occupation or vocation. If you are retired, please tell us what you did prior to retirement. If you are a student, please indicate your area of study.
Your answer
Foreign language / fluency *
Please indicate the foreign languages that you speak and the level of fluency
Your answer
Other countries in which you have lived or visited *
Your answer
PASSPORT INFORMATION
Please provide us with the following information exactly as it is recorded on your passport. Note that you must have a valid passport that expires no sooner that 6 months after the conclusion of the Travel Study Seminar.
Passport Number *
Your answer
Surname *
Your answer
Given Names *
Your answer
Nationality *
Your answer
Date of birth *
MM
/
DD
/
YYYY
Place of birth *
Your answer
Date of issue *
MM
/
DD
/
YYYY
Expiration date *
MM
/
DD
/
YYYY
Sex *
Authority *
Please let us know the entity that issued your passport, if indicated
Your answer
APPLICATION QUESTIONS
These questions will help us know more about your involvements in peacemaking and motivations to participate in this particular seminar.
What are your reasons for desiring to partipate in this travel study seminar? *
Your answer
What are your expectations for this experience? *
Your answer
What involvement, if any, have you had in working for peace and justice in your church or community? *
Your answer
What interests/skills/background do you bring which will enrich the experience for yourself and for the group? *
Your answer
What experience have you had working or traveling in other countries? Are you adaptable to simple accommodations? *
Your answer
What do you hope this travel study seminar will do, change or inspire in you, to take action in your church or community? *
Your answer
Write a brief biographical paragraph about yourself, your work, interests, family and church involvement (to be shared with other on the trip). *
Your answer
REFERENCES Please provide two personal references [please include one reference from within your presbytery or synod).
Name, relationship to you, Known years, telephone, email
Your answer
HEALTH AND INSURANCE INFORMATION
All health and insurance information will be kept confidential and used only for the purposes of this travel study seminar.
My general health is *
I am a smoker *
I have alergies *
If yes, please explain:
Your answer
I have physical restrictions *
If yes, please explain:
Your answer
I have dietary restrictions *
If yes, please explain:
Your answer
Are you currently under a physican's care/or taking prescription medication? *
If yes, please explain:
Please list all medications that you will need to have with you on the seminar:
Your answer
Are there any other special considerations we should know about in considering your application?
Please expalin:
Your answer
Health Insurance Company
Your answer
Policy and Group Number
Your answer
Policy Holder's Name
Your answer
Insurance Authorization Phone Number
Your answer
Do you have insurance that covers
EMERGENCY CONTACT
Please identify a person whom we would contact in the event of an emergency while on the Travel Study Seminar.
Name *
Your answer
Relationship to you
Your answer
Emergency contact phone number *
Your answer
Emergency contact email *
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms