YWAM Nanaimo Student Application
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Course Applying For: *
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PERSONAL INFORMATION
Given Names: *
Surname: *
Gender: *
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Date of Birth *
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Country of Citizenship: *
Country of Birth *
Email: *
Phone Number: *
Are you married or have children accompanying you? *
If yes, please list names and birthdays. *
MAILING ADDRESS
Apt/ House Number: *
Street: *
Town / City: *
Province / State: *
Postal / Zip Code: *
Country: *
MINISTRY INFORMATION
Highest level of education completed:
Current Occupation:
Skills, Hobbies, Interests:
Conversion Experience: *
Current Relationship With Jesus: *
What are some areas you hope to grow in during your time with us: *
Do you currently have up to date vaccinations:
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Do you have any criminal convictions: *
EMERGENCY CONTACT INFORMATION
Please provide information for a contact in the event of an emergency.
First Name: *
Surname: *
Phone Number: *
Email: *
Address: *
Relationship To You: *
YWAM Agreements
Please read the following and if you are unsure of its meaning contact us for more explanation. The undersigned does hereby consent to taking part in noted activity organized by YOUTH WITH A MISSION-YWAM (herein referred to as YWAM), a religious non-profit corporation, with full understanding insofar as such  activity will involve missions and sporting activity and mingling with other individuals and groups, that treatments,  and incidental loss and expense, and the undersigned does for him/herself assume the risk of such expense, does wholly release YWAM from any responsibility or liability, and waives any claims or causes of action against it, it’s agents, it’s employees, or volunteer assistants that might arise on account of loss, injury or expense occasioned by  any sort of accident or other circumstance involving him/herself and agrees to hold harmless YWAM in the event any  such claims should arise; and  The undersigned agrees to abide by the rules and regulations, supervision and discipline set and applied by YWAM  and it’s agents, and does hereby authorize YWAM or it’s staff members or other agents to arrange for and consent to  x-ray examinations, anesthetic, dental, medical or surgical diagnosis, and treatment, and hold harmless YWAM for  any such. The undersigned will furnish payment or insurance for any such payment, at his/her own expense. *
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