Attach photo here. P.O. Box 40 • Hillsboro, NH • 03244 Phone: (603) 464-5555 • Fax: (603) 464-5658 • www.hismansion.com Internship Application Personal Information Name _______________________________________ Age _____ Date of Birth _______________________ Current Address __________________________________________________________________________ City ______________________________________________________ State ______ Zip ________________ Primary Phone (_______) ______________________ Secondary Phone (_______) _____________________ Permanent (Mailing) Address ________________________________________________________________ City ______________________________________________________ State _______ Zip _______________ E-mail Address _______________________________________ Height _________ ft/in Weight _______ lbs Marital Status ___ Single ___ Engaged ___ Married ___ Widowed ___ Separated ___ Divorced Emergency Contact Information Name ________________________________________ Relationship ________________________________ Address _________________________________________________________________________________ City ____________________________________________________ State ________ Zip ________________ Primary Phone (______) _______________________ Secondary Phone (______) ______________________ E-mail Address ___________________________________________________________________________ Education Current School Name ______________________________________________________________________ Address _________________________________________________________________________________ City ______________________________________________________ State ________ Zip ______________ Major(s) ______________________________________ Minor(s) ___________________________________ Year in School _______________ Anticipated Graduation Date _____________________________________ List all other high schools, colleges/universities, or graduate schools you have attended. School Name Location Dates Attended Graduation Date Degrees _________________________________________________________________________ 1 If you left school prematurely, please explain why. __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Employment Are you currently employed? ___ Yes ___ No a. Company Name ____________________________________________________________________ b. Position ________________________________________________ Full-Time _____ Part-Time _____ c. Length of Employment _______________________________________________________________ d. Supervisorʼs Name __________________________________________________________________ May we contact your employer? ___ Yes ___ No If not, why not? _____________________________________________________________________ Approximately how many other jobs have you had? _______________________________________________ Have you served in the military? ___ Yes ___ No If yes, how long? ____________________ What branch? ____________________________________ Please list previous employment/service experience that would be relevant to your service at His Mansion. ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ If you have ever had to leave or been asked to leave an employment or service position prematurely, please explain the occurrence in detail on a separate sheet of paper. Church Information – Please provide information about your current church community. Church Name ____________________________________________________________________________ Pastorʼs Name ___________________________________________________________________________ Address _______________________________________________ City ______________________________ State _____ Zip _______________ Primary Phone: (_______) ______________________________________ E-mail Address ___________________________________________________________________________ Are you a member? ___ Yes ___ No How long have you attended there? _____ Years _____ Months Have you discussed your intent to serve at His Mansion with your pastor? ___ Yes ___ No May we contact your pastor to discuss your candidacy? ___ Yes ___ No If not, why not? _____________________________________________________________________ 2 Personal History Please answer all of the following questions. Answering “yes” to the following questions will not necessarily disqualify you from service. Please provide a brief explanation for any item that you have checked “yes.” Feel free to attach a separate sheet for short explanatory answers to these questions. Please list and explain any medical conditions or health issues. ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Have you received any diagnosis from a mental health professional? ___ Yes ___ No If yes, what is the diagnosis? __________________________________________________________ Do you take any prescribed medications pursuant to a physician's direction? ___ Yes ___ No If yes, please list the medication and dosage? __________________________________________________________________________________ Is your diet restricted? ___ Yes ___ No If yes, explain. __________________________________________________________________________________ Do you have any allergies (e.g. drug, food, seasonal, animal, etc…)? ___ Yes ___ No If yes, explain. __________________________________________________________________________________ Have you ever had (or currently have) back problems? ___ Yes ___ No If yes, explain. __________________________________________________________________________________ Does anything hinder you from doing physical work, including heavy lifting? ___ Yes ___ No If yes, explain. __________________________________________________________________________________ __________________________________________________________________________________ Have you ever had an eating disorder? (Anorexia, Bulimia, etc…) ___ Yes ___ No If yes, explain. __________________________________________________________________________________ __________________________________________________________________________________ Have you ever used illegal drugs? ___ Yes ___ No If yes, explain. __________________________________________________________________________________ __________________________________________________________________________________ 3 Have you ever had a problem with substance abuse? ___ Yes ___ No If yes, explain. __________________________________________________________________________________ __________________________________________________________________________________ Have you ever struggled with same-sex attraction? ___ Yes ___ No If yes, explain. __________________________________________________________________________________ __________________________________________________________________________________ Have you ever been hospitalized for emotional or behavioral issues? ___ Yes ___ No If yes, explain. __________________________________________________________________________________ __________________________________________________________________________________ When and where were you hospitalized? __________________________________________________________________________________ Have you ever been abused (mentally, emotionally, physically, or sexually)? ___ Yes ___ No If yes, explain (use a separate sheet if necessary): __________________________________________________________________________________ __________________________________________________________________________________ Have you ever been an abuser (mentally, emotionally, physically, or sexually)? ___ Yes ___ No If yes, explain (use a separate sheet if necessary): __________________________________________________________________________________ __________________________________________________________________________________ Describe your exposure to pornography. ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Describe your sexual history. ________________________________________________________________________________________ ________________________________________________________________________________________ Have you ever been charged with or convicted of a criminal act, regardless of whether the conviction was later set aside or expunged? ___ Yes ___ No If yes, please provide the details of the offenses charged and the outcome – including sentencing, if applicable. __________________________________________________________________________________ __________________________________________________________________________________ 4 Essay Questions This application is not merely evaluative, but is also an opportunity for the internship staff to get to know you. Your answers to the following questions will help us get to know you, while taking a reflective posture towards yourself. Please answer the following questions thoroughly, honestly, and thoughtfully on a separate sheet of paper in no more than two paragraphs per question. 1. Who are you? 2. Describe your past and present relationship with your mother and father (each separately). 3. Who has been the most influential person in your life? Why? 4. What is your greatest accomplishment in your life thus far? 5. What is your greatest regret in your life thus far? 6. Describe your relationship with God. 7. How did you come to know God? 8. In your understanding, what is the Gospel? 9. What do you believe about the Bible? What role does it play in your life? 10. How do you handle conflict in your relationships? References Please list three people we may contact for reference. Avoid using relatives or close friends. Please use other appropriate people, such as pastors, elders, ministry leaders, mentors, etc. 1. Reference One Name ________________________________________ Relationship ________________________________ Address _________________________________________________________________________________ City ______________________________________________________ State ________ Zip ______________ Primary Phone (______) _____________________ Secondary Phone (______) ________________________ E-mail Address ___________________________________________________________________________ 2. Reference Two Name ________________________________________ Relationship ________________________________ Address _________________________________________________________________________________ City ______________________________________________________ State ________ Zip ______________ Primary Phone (______) _____________________ Secondary Phone (______) ________________________ E-mail Address ___________________________________________________________________________ 5 3. Reference Three Name ________________________________________ Relationship ________________________________ Address _________________________________________________________________________________ City ______________________________________________________ State ________ Zip ______________ Primary Phone (______) _____________________ Secondary Phone (______) ________________________ E-mail Address ___________________________________________________________________________ Please read the following statement and sign below. I hereby certify that the answers and other information on this application are true and correct to the best of my knowledge. I understand that any material misrepresentation or omission of facts on my part will be grounds for dismissal from my internship at His Mansion Institute. Signature ________________________________________________ Date ___________________________ PLEASE MAIL YOUR APPLICATION TO: His Mansion Ministries P. O. Box 40 Hillsborough, NH 03244-0040 Attn: Dave McHale, Internship Supervisor 6