Kairos Adventure Guide Application
Personal Information
Name
First Name
Last Name
Email
example@example.com
Phone Number (or WhatsApp if international)
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Date
Sex
Male
Female
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Name
First Name
Last Name
Parent/Guardian Phone Number
Please enter a valid phone number.
Parent/Guardian Email Address
example@example.com
Current year in school/university
Program Information
Do you have any unmissable family obligations between June 11 and August 5? If yes, please tell us of the event and the dates:
The cost of Kairos Adventure Guide (KAG) is between $3500 - $4000. We will give you all of the training, support, and resources necessary for you to fundraise the full amount. If accepted, are you willing to do the fundraising?
During KAG, individuals will live in close proximity to one another and will have common commitments and responsibilities. If accepted, are you willing to participate fully in common commitments of household/program life?
Why are you interested in KAG?
Please describe your prayer life
Why do you think you would be a good fit for KAG?
Have you ever abused alcohol or been dependent on alcohol? If yes, please clarify.
Are you currently using tobacco products?
Medical Information
All information given below will be kept confidential
Current Medications (if any)
Date of Last Tetanus Shot
*
-
Month
-
Day
Year
Date
Immunizations and date of last booster
*
Health Insurance Provider
*
Card Holder's Name
*
Policy Number
*
Doctor's Name
*
Doctor's Phone Number
*
Please enter a valid phone number.
Do you experience any of the following?
*
Asthma, Wheezing, Hay Fever
Stomach/bowel problems
Diabetes/Hypoglycemia
Convulsions,/Seizures
Fainting spells
Thyroid problems
Epilepsy
Heart problems
Allergies (environmental, medications, latex)
Shortness of breath
Operation/Injury
I do not experience any of these
Please explain any such conditions. If there is a need to take you to the hospital the information on this form will be used to assist in giving you the best possible care. Therefore, give as much information as you would to an emergency room physician. If you have a chronic health condition, please include details about the condition. For example: If you have asthma, is it exercise induced? What triggers an attack? Is it controlled with medication? What medication, dose and frequencies? Has you ever been hospitalized for an asthma attack? If yes, how frequently and when was the last admission? If you have an allergy please include the type of reaction (redness, rash, hives, difficulty breathing). Should we need to take you to the emergency department, your emergency contact will be notified as soon as possible.
Please inform us if you have in the past or are currently experiencing any of the following?
*
Depression
Anxiety
Panic Attacks
Eating Disorders
Self Harm
Suicidal Thoughts
Other Mental Health Conditions
I do not experience any of these
In the space below, please explain any such conditions including any treatment you're receiving
Please inform us of any dietary allergies you may have--kindly also inform us of their severity.
Reference
Please provide us with a reference. If you're actively involved in a youth group, this should be your youth group leader or small group leader
Reference Name
First Name
Last Name
Nature of relationship to reference
Reference Number
Please enter a valid phone number.
Reference Email Address
example@example.com
Please indicate your level of involvement, if any, to your local youth group or outreach. With 1 being no involvement and 5 being extremely involved.
If you have a pastoral leader or mentor within your community, please list their name, email, and phone number.
By checking below, I certify that the information I have given is true and accurate to the best of my knowledge. I understand any misrepresentation of the above information could cause me to be excluded or removed from the program.
I agree
Application Process
Fill out this application
Kairos Staff will reach out and schedule an interview
Within 2 weeks of your interview Kairos will send you an email letting you know our decision on your application
If you are offered a spot in KAG, you will have 2 weeks to either accept or reject the offer
Submit
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