GENERAL INFORMATION

Year you wish to begin study? *

Name *

Social Security Number *

Birth Date *

Sex *

Male

Female

Upload Your Photo *

Marital Status *

Single

Married

Divorced

Widowed

Children? *

Yes

No

# of Children

Mailing Address *

Country

City

State

Zip code

Cell Phone *

Email Address *

Country of Citizenship *

If not a U.S. Citizen, check type of visa:

Student

Permanent Resident

Visitor

Dependent

Is English your primary language? *

Yes

No

If no, what language is?

Name of parent(s) or guardian(s) with whom you reside (if applicable)

Parent or Guardian Cell Phone *

Parent or Guardian Email Address *

Next of kin name: *

Next of kin address: *

Country

City

State

Zip code

List names and state relationship of any relatives who have attended or are attending Leaders Academy.

EDUCATIONAL INFORMATION

Name of High School

School Phone Number

School Fax Number

School Address *

Country

City

State

Zip code

Date of Graduation

Did/Will you graduate early?

Yes

No

From which type of high school did/will you graduate?

Public

Private

Home School

Date you took/will take the GED (if applicable)

GED Total Score

Date you took the ACT:

ACT Total Score

Date you took the SAT:

SAT Total Score

Have you ever been dismissed, place on probation or required to leave school for any reason? *

Yes

No

If yes, please explain the circumstances in your Biographical Essay.

ACTIVITIES AND AWARDS

Please list any church/community involvement, extracurricular activities, special awards or recognitions:

MEDICAL HISTORY

Please complete the Medical History section. The information given is kept confidential.

Name *

Sex *

Male

Female

Birth Date *

Marital Status *

Single

Married

Divorced

Widowed

Home Address *

Country

City

State

Zip code

Phone # *

Name of Parent, Guardian, or Spouse *

Parent, Guardian, or Spouse Home Address *

Country

City

State

Zip code

Parent, Guardian, or Spouse Home Phone *

Cell Phone *

Are you under treatment for anything medical, surgical, or emotional? *

Yes

No

(If yes, explain)

Prior Hospitalizations? *

Yes

No

(If yes, explain and list name and address of attending physician for these conditions)

Family Physician *

Phone # *

Physician Office Address *

Country

City

State

Zip code

Your Height (in feet and inches): *

Your Weight (in pounds): *

Date you received a Tetanus shot? (within 10 years)

Date you received a Polio shot? (5 years through age 19)

Any other shots? Please describe:

Date of Skin Test and/or chest x-ray in last 6 months:

Skin or chest x-ray results:

List any prescriptions you take, if any:

List non-prescription (illegal) drugs previously used:

FAMILY HISTORY

Father's Name *

Father's State of Health *

Father's Occupation *

Father's Age at Death

Father's Cause of Death

Mother's Name *

Mother's State of Health *

Mother's Occupation *

Mother's Age at Death

Mother's Cause of Death

Brother's Name

Brother's State of Health

Brother's Occupation

Brother's Age at Death

Brother's Cause of Death

Sister's Name

Sister's Occupation

Sister's State of Health

Sister's Age at Death

Sister's Cause of Death

Student Signature

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Date *

Parent Signature

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Date *

CODE OF HONOR PLEDGE

Please read the following statement thoughtfully before signing. If accepted to Applied Life Leaders Academy, your continued enrollment will depend on your working within these guidelines. Applied Life Leaders Academy is dedicated to providing a quality internship within the Christian framework. Our vision is to motivate the next generation to passionately pursue Jesus Christ and to equip them with the life skills necessary to reach their full potential in Christ. Leaders Academy is designed to teach this culture how to take God’s Word and apply it to their everyday lives so that they can achieve the victories that God has for them. Applied Life Leaders Academy takes seriously its part in developing your leadership and is committed to providing the following:

An opportunity to grow
A stimulating spiritual environment
Assistance in finding God’s direction for your life
An interdependence and commitment to the body of Christ which is the church

The Leaders Academy is not responsible for illness, theft, accidents on or off campus or any other mishap of personal detrimental nature. It is expected that you will take your responsibility as an intern seriously. We treasure students who strive for and maintain high moral and ethical standards and who can contribute to this high quality of life on our campus. As part of our commitment to provide a distinctive lifestyle experience, the Leaders Academy prohibits on and off campus possession or use of alcoholic beverages, illegal drugs, tobacco, gambling, sexual misconduct, cheating, theft, and conduct inconsistent with the goals of this ministry. An important element of “community” at the Leaders Academy is corporate worship and fellowship. Therefore, church attendance is required. If admitted to Applied Life Leaders Academy, I will

3) Work to make a positive contribution to the Leaders Academy community Applied Life Leaders Academy reserves the right to dismiss any student who chooses not to live up to the standards set forth by the Leaders Academy. (All tuition and fees paid are non-refundable).

Student Signature

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Date *

Parent Signature

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Date *

UPLOADS

Biographical Essay *

Answer the following questions in a double-spaced typed essay in two pages or less.

1. Please explain your personal relationship with Jesus Christ. What does it mean to you to be a follower of Christ?
2. Please tell us about the persons, places and events that have influenced your life.
3. What contribution do you feel you can make to the Applied Life Leaders Academy community?

High School Transcript or GED *

If you don't have this yet, just upload a word doc or pdf stating you don't have it yet and when you expect to receive it. Once you receive it, please email to addmissions@appliedlife.com.

Official ACT and/or SAT Scores

If you don't have this yet, just upload a word doc or pdf stating you don't have it yet and when you expect to receive it. Once you receive it, please email to addmissions@appliedlife.com.

Official Immunization Records *

If you don't have this yet, just upload a word doc or pdf stating you don't have it yet and when you expect to receive it. Once you receive it, please email to addmissions@appliedlife.com.

PERSONAL INFORMATION

Why do you desire to attend Applied Life Leaders Academy? *

How did you first hear about Applied Life Leaders Academy? *

List other internships to which you have applied:

Have you ever been convicted, plead guilty or no contest to a felony charge? *

Yes

No

I declare that all information given is true to the best of my knowledge. I have read and, if accepted to Applied Life Leaders Academy, agree to abide by the Code of Honor Pledge.

Student Signature

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Date *

Please click the Submit button one time only. It may take up to 2 minutes for your submission to process.

GENERAL INFORMATION

EDUCATIONAL INFORMATION

ACTIVITIES AND AWARDS

MEDICAL HISTORY

FAMILY HISTORY

CODE OF HONOR PLEDGE

UPLOADS

PERSONAL INFORMATION

CONTACT US

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Phone:

Address:

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