Character Seminars for Ukraine - Application

Personal Information

Please complete all fields below.

Full legal name as it appears on passport:

*Preferred name:

Address:

Line 1:

Line 2:

City:

State:

Zip:

Phone:

Phone 1:

Phone 2:

Personal Email:

Other Email:

Passport Number:

Passport Date Issued:

Passport Expiration Date:

Birth Date:

Closest Regional and International Airport:

Church Family Affiliation:

Professional Information

Occupation:

Previous Occupations:

Positions:

Professional Awards :

Memberships:

Previous Certifications:

Educational Information

Undergrad

List institution

Degree

Field

Master's Degree

List institution

Degree

Field

Doctorate Degree

List institution

Degree (e.g., PhD, EdD, MD, PsyD, J.D., ABD)

Field

Post Graduate

List institution

Field

Communication

Public Speaking Experience

Public Speaking Engagements

Classroom Teaching Experience

Seminars or Training Engagements

Other

General Questions

Describe your temperament and work style:

Describe how you would work in a situation that may include: communication boundaries, limited food options, and perhaps shared sleeping quarters:

Are you willing to make changes in personal habits or dress to avoid being offensive in a foreign culture? YesNo

Are you willing to attend and participate in a weekend training seminar? YesNo

Eastern European Mission is a non-political, non-profit organization. We do not exist to promote a political agenda of any nature. Our funds are solicited within the United States; as such we do not actively solicit funds in the countries we serve. We are an international and humanitarian organization serving a variety of nations. As a result we respect the sensitivities and concerns of all cultures. Our goal is to share the Bible with any who wish to read it and to promote character consistent with Judeo-Christian ethics. Our goal is not to present American or Western culture as somehow superior or the ideal. We promote a spirit of graciousness, kindness, and sensitivity to all individuals, communities, and cultures we come in contact with. Are you willing to abide by the spirit and mission/intent and policies of Eastern European Mission? YesNo

Where did you hear about this opportunity?

Have you ever been convicted of a felony? If yes, explain.

Costs

The general per-person cost of the trip is approximately $3,000-$4,000. If selected what portion of the trip would you have the ability to self-fund or raise?

International Experience

Have you traveled internationally? YesNo

If "yes" describe fully:

…to which countries?

…in what capacity?

…your best experiences

…your worst experiences

Do you have any experience with international students or clients? Explain:

Spiritual Survey

When did you become a Christian?

Please describe your personal walk with the Lord at this time:

Please share some of your personal ministerial strengths as they would relate to this trip:

Please share some of your personal ministerial weaknesses as they would relate to this trip:

Physical Assessment

Do you have any limitations related to walking or mobility? YesNo

If yes, please explain.

Do you have any medical conditions for which you are currently receiving treatment? YesNo

If yes, please explain.

Do you have any physical limitations or disabilities? YesNo

If yes, please explain.

Are you presently being treated for any mental or emotional conditions? YesNo

If yes, please explain.

Are you currently taking any medications? YesNo

If yes, please list them.

Physician's Name:

Physician's Phone Number:

Personal and Professional References

Please list 2 references. It is your responsibility to provide your 2 references with a printed EEM reference form from this site or with instructions for accessing the online reference form from this site. EEM will not contact these names about receiving your references. Each reference needs to be an unrelated/non- family member who has known you for at least 3 years. One reference needs to be filled out by a church minister or church leader and the 2nd by an employer, co-worker or professor.

Professional Reference Name:

Relationship to you:

Personal Reference Name:

Relationship to you:

Emergency Contacts

Next of Kin:

Name:

Phone:

E-mail:

Emergency Contact #2:

Name:

Phone:

E-mail:

Hold Harmless Agreements

I AGREE TO RELEASE, HOLD HARMLESS AND INDEMNIFY FROM ANY AND ALL CLAIMS ASSERTED BECAUSE OF ANY INJURY TO MYSELF, Eastern European Mission | Character International, all of its affiliates, and all individuals, named and otherwise, participating with the explicit approval of the duly authorized representative of Eastern European Mission and Character International, including but not limited to volunteers, from any and all damages arising during the period of my participation in the EEM | Character International Program as I travel to Ukraine and return to the United States. I do hereby agree to hold Eastern European Mission | Character International harmless and agree to indemnify fully Eastern European Mission and Character International for any and all judgments and damages rendered against it and including costs, attorney's fees, regardless of whether or not there is litigation and including mediation and arbitration proceedings which result from or that are in any way connected with monetary, physical, mental, emotional or other type claim of injury to me that is claimed or asserted.

I have read and agree to the above terms.

Acknowledgement

I understand that I am responsible for contacting my 2 references about submitting reference information.I acknowledge that all information is current and correct.

Electronic Signature:

Note: Typing your name into the box above legally serves as your signature for this electronic form.

Today's Date:

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