LifeReach International A Ministry of Youth With A Mission El Paso & Juárez Program Application Forms Please complete all the questions on the application. Please type or print clearly in ink and use a separate sheet when necessary. When completed please submit to: LifeReach International 4444 Edgar Park Ave. El Paso, TX 79904 USA Telephone: 1.915.757.3387, Fax: 1.915.755.5727, Email: LifeReach@ywamepj.org (Further inquiries: Program Coordinator is Consuelo, lifereach@juno.com) Personal Information Full legal name: Permanent address: Last, First Middle/Maiden Applying for: Program: Location: Dates: Telephone: Mobile: Email address: Present address, if different: Business Telephone: Mobile: Email address: Age: Date of Birth: Female or Male Please submit 2 passport size photos Month/ Day/ Year Passport and/or Legal Identification (with photograph) Number: Date of Expiration: Please submit a copy of passport/legal ID Date & Place of issue: Emergency contact information: Family Information Name &Relationship Telephone or best method of contact Marital status: If married, name of spouse: Do you have children? Will any family members accompany you in the program? 1
Church Information Home Church: Church Address: How long have you been a born again Christian? How long have you attended there? Pastor: What has been your Christian experience? Are you presently ordained or licensed? Yes No If yes, please specify: Describe your relationship with your local church; include areas of service and leadership. Have you had any missions experiences? Yes No Who would be able to give a recommendation for you? Email & Mailing Address: If so, where and what type of ministry were you involved in? Telephone: Education, Employment and Skills Highest level of education completed: Post-high school program(s) attended: What languages do you speak?: Military Service? Yes No If yes please specify: Present Employer & Occupation: Occupational Skills & Yrs. of Experience: Other skills, talents, hobbies, interests: Who would be able to give a recommendation for you? Email & Mailing Address: Telephone: Experience with YWAM Have you ever been involved in a YWAM short-term outreach or training program? Yes No Dates: If so, please give location, program and leader's name: Any other YWAM programs? Who would be able to give a recommendation for you? Email & Mailing Address: Telephone: What are your plans and goals after you complete this program? 2
Financial Information The program fees do not cover transportation or air fare, to and from your field/educational sites. Nor do they cover any visas or work permits you may need. Please ask about these expenses if they have not been made clear to you. Do you have the total program fees? Yes No If not, please contact our program coordinator for the cut-off date for fees. Certifications & Agreement I certify that all information in this application and all its additional forms, is complete and accurate. If accepted by LifeReach International and Youth With A Mission El Paso & Juarez (YWAM), I will abide by the guidelines, rules and schedule of the program. I understand that payment of the required program tuition and other fees must be made before arrival. I am also fully aware of my financial obligations and commit myself to expeditiously paying all personal expenses incurred during my involvement with LifeReach International and YWAM. Signature: Guidelines for completing the Program Application 1. Program Application form. Please answer every question. If one does not apply to you, write N/A in the blank. Husbands and wives should complete separate applications. 2. Application Fee. A non-refundable registration fee of $35 for singles or $50 for a married couple is to be sent in with the application. 3. Confidential Health Form. This form must be signed and dated. You may also need to get a release signed by a physician. We will advise if needed. 4. Consent for Treatment / Liability Release/Burial on the Field & Covenant forms. Each applicant must sign these forms to join the program. If the applicant is under 18 years of age, a parent or legal guardian must also sign the forms and may be required to accompany the child onto the field. 5. Supplemental questions. Each program has a set of questions associated with it. Please answer each question concisely and use a separate piece of paper as needed. Please print or type. How did you hear about LifeReach International and our programs? Please list any special circumstances or situations we should know about. 6. References. Applicants are asked for at least two references who could recommend them. Please let them know that we may call them. If you do not have two already listed above, please do so here: Name: Relationship: Telephone: Email & Mailing Address: Name: Relationship: Telephone: Email & Mailing Address: 7. Send all requested copies, photos, fees, and additional information to: LifeReach International 4444 Edgar Park Ave., El Paso TX 79904 USA Fax: 1.915.755.5727 or scan and email: lifereach@ywamepj.org 3
Confidential Health Form (This will be on file at your field location) Name: Emergency contact information: Program applying to: Name &Relationship Telephone or best method of contact It is a requirement that all participants have insurance. If you do not, we may be able to make suggestions but it is your responsibility to procure before your arrival and to notify us of the: Medical Insurance Company Name Insurance card # Telephone contact or instructions: Personal Health History - please circle any of the following conditions that you have had, or currently suffer from: Skin conditions Eye trouble Ear trouble Head injury Recurrent headache Epilepsy Fainting spells Mental / Nervous disorders Weakness Paralysis Insomnia Allergies Penicillin Other- Specify Food- Specify Other This program will require good health and endurance. Shortness of breath Hay Fever / Asthma Heart trouble High blood pressure Low blood pressure Rheumatism / Arthritis Back problems Dislocation of joints Broken bones Eating disorders Anorexia Nervosa Bulimia Surgery Appendectomy Hernia repair Tonsillectomy Other- specify Stomach/Duodenal Ulcer Gall bladder problems Jaundice Hepatitis Intestinal troubles Recurrent diarrhea Diabetes Kidney Disease Anemia Venereal Disease HIV /AIDS Tumors/Cancer Females only: Irregular periods Severe cramps Excessive flow Pregnant now - # of weeks Due Please explain anything that you circled using another sheet as needed. Are you currently under a doctor s care for any condition? Yes No (specify) Are you taking any medication at this time? Yes No (specify) Any physical handicaps or health conditions which require special attention? Yes No (specify) Do you have a history of emotional instability or psychiatric treatment? Yes No (specify) Are you overweight underweight Pounds/Kg over/under Blood Type: Would you rate your health condition as: Excellent Good Fair Poor Communicable Diseases/Immunizations Have you been exposed to, or have, any of the following: Chickenpox Mumps Pertussis Measles Tuberculosis Scarlet Fever Other (specify) It is your responsibility to contact CDC or your local health office to verify country specific recommendations for immunizations and anti-malarial medication advise. Most field locations suggest protection from Hepatitis and Tetanus. Are you up-to-date on needed immunizations? Yes No Date compliant: **Records may be required of you.** Are there any other conditions/situations, we need to be aware of? Applicant s signature: 4
Consent for Treatment during Emergency Care I / We hereby agree to the performance of such treatment, anesthetics, and operations as is deemed necessary, in the opinion of the attending physician for: Applicant's Full Name: Applicant s signature: Parent/Guardian name, signature & relationship: (if applicant is under 18 yrs old) Liability Release I / We hereby release Youth With A Mission El Paso & Juarez, its agents, employees, and volunteer assistants from any liability whatsoever, arising out of any injury, damage, or loss, which may be sustained by said person during the course of involvement with LifeReach International and Youth With A Mission El Paso & Juarez. Applicant s signature: Parent/Guardian name, signature & relationship: (if applicant is under 18 yrs old) Notary Public: 5
Statement of Burial on the Field Although it is most unlikely that any volunteer or student with LifeReach International or Youth With A Mission El Paso & Juarez (YWAM) will pass away during his or her time of service on the field, existing laws regarding burial make it necessary to consider this possibility prior to travel abroad. On many locations in countries in which YWAM works, interment must take place within 24 hours of death. If death occurs, it is often not possible to make arrangements for returning the remains to the home country, and interment must take place on the field. Often, when arrangements to return the remains to the home country can be made, it is very expensive and some countries require that a living person accompany the deceased. For that reason, we cannot guarantee the return of the body to the home country. Signing this form does not mean that you cannot be buried at home, if you so desire. We will check with your family concerning their preferences. This form releases LifeReach International and Youth With A Mission from liability if your family is not willing to pay the costs, or if we are unable to contact them within the required amount of time. Therefore I/we would like you to consent to the following: In the event of my death, I give my permission to be buried in the country of my service. Printed Name: Signature of Applicant: Name and signature of parent or legal guardian if participant is under 18 years of age: Printed Name and relationship: Signature of Parent/Guardian: 1) Name of witness: Address: Occupation: Signature of witness: 2) Name of witness: Address: Occupation: Signature of witness: 6
Student & Volunteer Covenant LifeReach International and Youth With A Mission El Paso & Juarez (YWAM) will endeavor to make your learning and outreach experience meaningful, as you join us in ministry. Our training programs and outreach opportunities are designed to encourage you in your walk with the Lord. It is our desire that your experience will be enjoyable, rewarding and challenging. Understand that developing spiritually requires taking responsibility for your own life and conduct, as both can testify as a witness of Christ in you to others. With that in mind, please read the following statements and sign as indicated: A) The Bible says that Christians should think on things that are excellent, and avoid the appearance of evil, therefore I will maintain the highest moral standards and personal witness through proper conduct. Refraining from use profane, obscene, or vulgar language and behavior; abstaining from drinking alcoholic beverages, using tobacco, pornography, or any type of illegal drug; nor will I possess any such substances during my time with LifeReach and YWAM. B) Neat and modest clothing must be worn at all times, especially because of our field assignment location, therefore I will respect others and myself by wearing appropriate clothing while participating with YWAM. I will respect the ministry request to meet the terms of the dress code standards of each location. These include, but are not limited to: longer shorts and skirts, jeans that are not tight, appropriate shoes or sandals, blouses covering the midriff and shoulders (no spaghetti straps) and wearing appropriate undergarments at all times. Regarding tattoos, one should cover them, especially during ministry/practicums and corporate meeting times. For church ministry women should be prepared to wear skirts, blouses or dresses with sleeves, or dress slacks. Men shall be prepared to wear nice trousers, belts, shirts with sleeves, socks, and shoes. Shorts or flip-flops are not suitable for ministry events (including Community Night meetings). Unless otherwise stated, leave all facial jewelry at home, removing jewelry retainers and men shall remove earrings for ministry outreach, or as required. Modest one-piece swimsuits for women and baggy-style swimsuits for men are appropriate attire for swimming events. *Field assignment locations may have specific clothing requirements which will be communicated to you before arrival. C) Media influences often distract us from developing friendships, thinking clearly, and reflecting on how to develop a deeper walk with the Lord, therefore I will not bring anything that would distract me from these goals. I will intentionally avoid music and media that mocks God, uses profane language or promotes/describes immorality. D) Christian growth involves self-discipline, which means accepting personal responsibility to live as unto the Lord, therefore I will be prompt to and attentive in all classes and activities. I will keep myself, my belongings, and my room neat and clean. I will respect the property, privacy, and rights of others. I will demonstrate respect toward my fellow classmates/outreach participants, staff, guests, and those in the community. I will seek to have a positive influence on those around me. E) The Bible instructs us to respect authority; therefore I will abide by the guidelines of LifeReach International, YWAM and program leaders. My signature indicates my desire to learn, to grow spiritually, to benefit others, and to make the most of my experience with LifeReach International, YWAM El Paso &Juarez, and their programs. Print Name: Signature: Youth With A Mission El Paso & Juarez leadership and staff reserve the right to disallow other items of dress and conduct not specifically listed in these guidelines if they are considered inappropriate. 7
Supplemental questions for Midwife Teacher Development Programs. Please give details of your general education and language fluency. Please give details of your midwifery education and achievements. How long has it been since you completed your basic midwifery training? What is your practice experience since your basic midwifery training? Please gives details (may also need copies) of current licenses, continuing education, peer review and personal protocols. Why do you wish to teach midwives? Please give details of any experience you have of mentoring students. What did you enjoy and what did you dislike in this process? Are you a YWAM missionary? Where and what year did you do your DTS? Have you taken any additional YWAM programs... BAS, IPHC? Do you have certification as a Childbirth Educator or Doula? Please specify organization and dates? Have you taken any advanced midwifery training or gained midwifery experience above basic services? If so, please give details and provide applicable documentation. 8
Midwife Teacher Self-Assessment The following checklist can be used as a self-assessment form or as part of teacher assessment profile. The skills list is extended to include the knowledge that the teacher must possess to practice this skill to the level required and the attitudinal skills required to underpin the practice. Skill Knowledge Attitude Always No Unsure Practice all clinical Biological and social sciences underpinning Reflective practitioner midwifery skills midwifery to advanced level Empathetic to mastery level Midwifery subjects to Women and advanced level newborn focused Applies research findings in practice Applies professional ethics Conduct simple Research using qualitative and quantitative methodologies Teach students effectively Assess students fairly Clear accurate, concise report and record keeping Management Good communicator Inter-cultural competence Basic epidemiology Basic statistics Analytical framework Research resources Learning styles Teaching and training methodologies:. classroom. clinical Assessment strategies Report writing National legislation on record keeping Educational management theories Timetabling and scheduling Curriculum design and development Curriculum monitoring Curriculum evaluation Communication techniques Presentation methodologies Listening techniques Counseling techniques Cultural taboos and customs Cultural identity Thorough Thoughtful Analytical Patient Good sense of humour Logical Considerate Develops rapport easily Careful Truthful Accurate Trustworthy Collaborative Methodical Calm Person-centered Respectful Name: Please bring this sheet with you. We will cover this in our seminar. 9
Supplemental questions for Midwife Students and Residents. Please give details of your general education and language fluency. Please outline why you would like to become a midwife? Why do you think you would be a good midwife? What type of practice would you like to have? Please outline any experiences you have had with pregnancy, labour, birth, newborn babies and after birth care of mothers. See charts below. What did you enjoy and what did you dislike in these experiences? What is your level of knowledge of basic midwifery and healthcare? Do you have any certifications or educational credit? Please specify. Are you enrolled in a midwifery program? Are you following specific guidelines to credential you as a legal practicing midwife? If so, please provide appropriate documentation from your program. What are your expectations from taking this program? If specific forms and validations are expected, you must communicate that in advance and may need to submit forms before admission. Are you a YWAM missionary? Where and what year did you do your DTS? Have you taken any additional YWAM programs... BAS, IPHC? Do you have certification as a Childbirth Educator or Doula? Organization and Date? Birth Experience Attended births as an Observer, Assistant Under Supervision, or Primary under Supervision from (month) (year) to (month) (year). Births Home Free-standing Birth Center Hospital Birth Center Hospital Totals As Observer Assisting Primary under Supervision Primary/Co-Primary Totals Birth-Related Experience Activity Home Free-standing Birth Center Health Clinic or other Location Prenatal exams Initial exams Postpartum exams Newborn exams Continuity of Care Clients Hospital Totals 10
Supplemental questions for Childbirth Educators and Labour Companions (Doulas). Please give details of your general education and language fluency. Please outline why you would like to be involved in mother and newborn health and support? Why do you think you would be a good labour companion/doula and/or Childbirth Educator? What type of practice would you like to have? Please outline any experiences you have had with pregnancy, labour, birth, newborn babies, postpartum care, teaching and supporting families. What did you enjoy and what did you dislike in these experiences? What is your level of knowledge of pregnancy, labour, helping labouring women, birth and baby care? Do you have any certifications or educational credit? Please specify. Are you enrolled in, or have taken a doula or childbirth educator course? Please specify. Are you following specific guidelines to be certified in either? If so, please provide documentation from your program. What are your expectations from taking this program? If specific forms and validations are expected, you must communicate that in advance and may need to submit forms before admission. Are you a YWAM missionary? Where and what year did you do your DTS? Have you taken any additional YWAM programs... BAS, IPHC? 11