Christ in the City: Year of Service
Application for year of service 2017-2018
Last Name
Your answer
First Name
Your answer
Current Address
Your answer
Permanent Address
Your answer
Email Address
Your answer
Current Address Valid Until
MM
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YYYY
Skype
Your answer
Home Telephone
Your answer
Cell Number
Your answer
Best Number to Contact you At
Your answer
Date of Birth
MM
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DD
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YYYY
Gender
T-Shirt Size
Sweatshirt Size (if different)
Other Languages
Your answer
Parish
Your answer
Parent's Name
Your answer
Parent's Phone Number
Your answer
Parent's Address
Your answer
Emergency Contact
Name
Your answer
Address
Your answer
Contact Number(s)
Your answer
Relationship to You
Your answer
General Information
Please check all that apply to you and fill in the requested information. Leave blank those choices that do not apply.
Date of Conversion:
MM
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DD
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YYYY
Please Specify
Your answer
Specify Religion
Your answer
Do you have an application pending with another organization?
If Yes, which one?
Your answer
Do you have a drivers license?
Will you bring a car?
I have applied to CIC in the past. Which year?
MM
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DD
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YYYY
When I applied, I
Physical and Mental Health
Certain mental and physical conditions may be worsened or can be incompatible with the
demanding lifestyle of CIC (i.e. long days, little control over diet, lack of sleep, intensity of
apostolate to the homeless etc.).While having these conditions may not disqualify you from
CIC, it is our desire for people to remain healthy during their time at CIC.

Please disclose everything that applies to you. CIC will hold the information given to us
as confidential, available only to those involved in the application process. Fill in the
requested information for all that apply to you. Leave blank those choices that do not
apply.

Are your now, or have you ever, seen a doctor on a regular basis?
If yes, please explain, including frequency of visits
Your answer
Are you presently taking prescription medication?
If yes, please explain. Give the name of the medication and the frequency of the dosage
Your answer
Have you been hospitalized over the past 12 months?
If yes, please explain
Your answer
Do you, or have you ever suffered from:
Please give details of any you have checked, or any other conditions
Your answer
Do you have any special dietary requirements due to a medical condition or due to preferences (i.e vegetarian/gluten-free)
Please explain
Your answer
Is there anything regarding your current physical or mental health situation that we need to know, which we haven't already asked?
If yes, please explain
Your answer
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