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BASIC INFORMATION

First Name

Last Name

Middle Name

Goes by (nickname)

Gender

Date of Birth

(mm/dd/yyyy)

Citizenship

List country of citizenship

Phone Number

### - ### - ####

Phone Number

Email (this will be one of our primary communication methods with you, so it should be the email address you check most often)

Do you have a Cafe 1040 t-shirt?

YesNo

T-Shirt Size

Facebook Name	Instagram Username
Skype Username	Twitter Handle

PROGRAM

Preferences

We have three bases that run similar overseas programs in North Africa, South Asia, and Southeast Asia. Which base location do you prefer?

Depending on the semester, some base locations are not going to be available.

The following semesters will be available based on your location preference.

What is the semester you would like to participate?

Preferences

We have three bases that run similar overseas programs in North Africa, South Asia, and Southeast Asia. Which base location do you prefer?

Depending on the semester, some base locations are not going to be available.

The following semesters will be available based on your location preference.

What is the semester you would like to participate?

Why did you choose Cafe 1040?

What are you hoping to gain from the Cafe 1040 program?

Why do you want to go to North Africa in particular? How do you feel about the heightened security protocol?

Why do you want to go to South Asia in particular?

Why do you want to go to Southeast Asia in particular?

Participating in the Cafe 1040 program requires you to raise support. What best describes your perspective on support raising?

ExcitedOkay with itOpen but nervousCluelessTerrified

HOW DID YOU HEAR ABOUT US?

How did you hear about us? (select all that apply)

Cafe 1040 Staff	The Traveling Team
Cafe 1040 Graduate	Perspectives
Cafe 1040 Current Program Participant	Missions Conference
Cafe1040.com	Missions Agency Referral
Social Media	Missions Agency Website
Internet Search	University/School
Church	Campus Ministry
Camp	Other

Which staff member? (Select all that apply)

Alyson H	Amy H
Elise W	Haley J
Jeff M	Jordyn B
Nicole M	Rachel T
Rebekah P	Reed H
Zach D	Other

Which staff member?

Which Traveling Team traveler?

Which Cafe 1040 graduate?

In what city/semester did you take Perspectives?

Which program participant?

Which conference?

Which missions agency?

Which form of social media?

What campus ministry?

What church?

Which camp?

Please Explain.

ADDRESS

Best Current Mailing Address

Street Address

Address 2

City

State

Zip

Permanent Address - if different from above

Street Address

Address 2

City

State

Zip

ADDRESS

Best Current Mailing Address

Address 1

Address 2

Address 3

City

State/Province

Zip/Postal Code

Country

EDUCATION

Are you currently in school?

If not in school, what is your status?

Are you interested in receiving college credit for your time overseas with us?

YesNo

School

Major

Minor, if applicable

When are you planning to graduate?

Please explain.

Do you have any plans after you graduate?

WELLNESS

Do you have any medical conditions or allergies that could affect wellness? This would include diseases, asthma, broken bones, surgeries, diabetes, etc.

If yes, please describe each condition or allergy and its effect on your wellness in detail.

Are you taking any regular medication?

If yes, please list medication(s) and purpose(s)

Do you ever deal with issues such as eating disorders, addictions, substance abuse, panic attacks, depression, etc. that affects your psychological well-being?

If yes, please describe in detail.

SPIRITUAL

When and how did you become a Christ-follower?

How would you describe your relationship with Jesus?

What is the Gospel?

Church Information

How would you describe your involvement with a local church community?

Name of church

City

State

PERSONAL

How would you describe your personality? Use any of the following questions to inform your answer: What areas of your personal make-up (behavioral patterns, desires, personality, etc.) would you like to grow in? What strengths and talents do you naturally bring to a team? How do you see yourself vs. how others see you?

STATEMENT OF FAITH

The Scriptures // The Bible is the inspired Word of God. In its original languages it is without error. With the help of the Holy Spirit, scripture is understandable to all believers and authoritative in life. God // There is one God who exists in three distinct persons (Father, Son and Holy Spirit). Jesus Christ is the Son of God, eternally begotten of the Father. He became flesh, being born of the Virgin Mary and conceived by the Holy Spirit. He lived a completely sinless life, died on the cross, and was raised to life on the third day. He will personally return to earth to judge the living and the dead. The Holy Spirit proceeds from the Father and the Son and lives within each believer. He regenerates, counsels, convicts, and is the seal of salvation. Mankind // We believe that man was created in the image of God to have fellowship with Him, but became alienated from that relationship through sinful disobedience. As a result, man is totally incapable of restoring right relationship with God by his own effort. Salvation // We believe that the shed blood of Jesus Christ on the cross provides the sole basis for the forgiveness of sins. Therefore, salvation only occurs when a person places their faith in the death and resurrection of Christ as the sufficient payment for their sin. The Church // The church is the body of Christ of which Jesus Christ is the Head. The members are those who have trusted by faith the finished work of Christ. The purpose of the Church is to glorify God by loving Him and by making Him known to a lost world.

I fully agree with Cafe 1040's statement of faith.I do not fully agree with Cafe 1040's statement of faith.

Specifically, why do you not agree with Cafe 1040's statement of faith?

MARITAL STATUS

Marital Status

Anticipated wedding date

mm/dd/yyyy

Wedding Date

mm/dd/yyyy

Name of spouse.

Is the person with whom you are in a relationship also applying?

Is your spouse also applying?

Name of person with whom you are in a relationship.

Please briefly explain, if you think necessary.

Do you have children who would go with you on the Cafe 1040 program?

Children name(s) and birth dates (mm/dd/yyyy).

LIFE STAGE

Please select the option that most closely corresponds to your financial position.

PARENT INFORMATION

*We will not contact your parents without your permission first.

First Name

Last Name

Spouse First Name, if applicable

Does this parent know that you are inquiring into Cafe 1040?

If no, why not?

What was his/her reaction?

Email Address

Parent Phone

Parent Cell Phone

### - ### - ####

Parent Home Phone

### - ### - ####

Parent Work Phone

### - ### - ####

Alternate Parent Phone, if applicable

Parent Cell Phone

### - ### - ####

Parent Home Phone

### - ### - ####

Parent Work Phone

### - ### - ####

I would like to enter in additional parent information (not listed above)

YesNo

PARENT 2 INFORMATION

Parent 2 First Name

Parent 2 Last Name

Parent 2 Spouse First Name, if applicable

Does this parent know that you are inquiring into Cafe 1040?

If no, why not?

What was his/her reaction?

Parent 2 Email Address

Parent 2 Phone

Parent 2 Cell Phone

### - ### - ####

Parent 2 Home Phone

### - ### - ####

Parent 2 Work Phone

### - ### - ####

Alternate Parent 2 Phone, if applicable

Parent 2 Cell Phone

### - ### - ####

Parent 2 Home Phone

### - ### - ####

Parent 2 Work Phone

### - ### - ####

REFERENCE 1

We may call a reference during your process to help us determine how to best serve you. This is a person who you consider a personal spiritual mentor, discipler, or pastor.

Reference 1 - First name

Reference 1 - Last name

Reference 1 - Description and length of their relationship with you and/or position in the church, if applicable.

Reference 1 - Best Phone

### - ### - ####

Reference 1 - Best Email

REFERENCE 2

Reference 2 - First name

Reference 2 - Last name

Reference 2 - Description and length of their relationship with you and/or position in the church, if applicable.

Reference 2 - Best Phone

### - ### - ####

Reference 2 - Best Email

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