Application Process (Please print in ink or type) by ezk20114

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									    Internship Application
    Please direct all responses and inquiries to:

            Shekinah Christian Church
               Attn: PLUGGED IN
                 P. O. Box 2485
              Ann Arbor, MI 48106

            Telephone: 734-662-6040
                Fax: 734-662-5470
      Email: internship@shekinahchurch.org
        Web: www.shekinahchurch.org




                                              Revised: 06/18/2007 
APPLICATION PROCESS

Thank you for your interest in PLUGGED IN. If you have any questions about the application process
or the internship, please contact our Office of Admission at 734-662-6040. You can also check out our
website at www.shekinahchurch.org or email us at internship@shekinahchurch.org



The application process at PLUGGED IN focuses on understanding the individual. Our admission
officers will work closely with each applicant throughout the application and enrollment process. Each
applicant will also be interviewed by our admission staff. Our admission process is designed to select
those applicants who will thrive in PLUGGED IN. We seek interns who want to grow spiritually, who
have the potential to be successful academically and who are willing and able to undergo rigorous
physical training. We will carefully and prayerfully consider your application, essays, interviews and
recommendations while making our decision.




APPLICATION CHECKLIST
For your application to be complete, you must submit the following:
       ❑ Application Form (including Statement of Agreement)
       ❑ $25.00 non-refundable application fee (make checks payable to Shekinah PLUGGED IN)
       ❑ High school transcripts (also send college transcripts if applicable)
       ❑ Two Essays
       ❑ Medical History Form
       ❑ Criminal and Background Records Check Form
       ❑ Two Recommendations
       ❑ Two recent, different photos (will not be returned)
Please note that we will not be able to make a decision concerning your application until we have ALL
of the above items.



APPLICATION DEADLINE
PLUGGED IN is a nine-month program that begins in September and ends in May. We accept and
review applications year round, but all applications for enrollment in the current year must be
submitted by August 1.




                                                                                 Revised: 06/18/2007 
TUITION DEPOSIT
If you are admitted to PLUGGED IN and plan to enroll, you must submit a non-refundable $300.00
tuition deposit, due by August 15, or within 30 days of admission, whichever is earlier. Prior to or on
the 1st day of the internship, $1700.00 must be paid making it half the tuition and the rest can be paid
off in 4 monthly payments of $500.00



SPECIAL INSTRUCTIONS FOR INTERNATIONAL STUDENTS
International students are required to have transcripts evaluated by World Education Services. Also,
international students whose first language is not English must submit TOEFL scores. Additionally,
international students who plan on acquiring a car upon arrival in the United States must give
themselves enough time to buy and insure it. We suggest at least two weeks prior to the start of the
program.



COMPLETING THE APPLICATION
1.   Please print legibly in ink or type the application form. Be sure to complete each page of the
     application and sign the Statement of Agreement. Mail the application and other materials to the
     Office of Admissions.
2.   Enclose the $25.00 non-refundable application fee. Check or money order is preferred. Your
     application for admission will not be evaluated until the application fee is received.
3.   Request official transcripts from your high school and/or any colleges attended. If you are
     currently enrolled, please request a final transcript to be mailed upon graduation or completion of
     coursework. Applicants who have completed fewer than 30 semester hours of college coursework
     must also submit high school transcripts.
4.   Request two recommendations using the forms included in this application. One must be
     completed by a pastor or youth worker (spiritual/pastor recommendation) and one must be
     completed by someone who knows you well but not a family member (personal recommendation).
     Recommendations should be mailed directly to the Office of Admissions. PLUGGED IN does not
     accept recommendations from family members.




                                                                                     Revised: 06/18/2007 
PERSONAL INFORMATION
I plan to enter PLUGGED IN: September
                                                     Year


Name:                                                                      Soc. Sec. #:
                 Last                        First             M.I


Preferred Name:                               Date of Birth:               Age:           Gender: ❑M ❑F

Present Address:
                         Number and Street                                                Apt/Suite


City:                                                                      State:                     Zip:


Home Phone:                                    Cell Phone:                                  Fax:


Email Address:


Are you a U.S. Citizen? ❑ Yes      ❑ No If no, what is your current U.S. immigration status?


Country of Birth:                                                Country of Citizenship:


Providing information about race/ethnicity is voluntary. The information is not used in a discriminatory
manner.

Select one (optional)
❑ Latino(a)/Hispanic     ❑ Caucasian     ❑ African American               ❑ American Indian or Alaskan Native
❑ Asian American         ❑ Pacific Islander      ❑ Other:


Name of Church/Christian Organization:


Mailing Address:
                         Number and Street                                                Apt/Suite


City:                                                                      State:                     Zip:


Name of Senior Pastor:


Name of Youth Pastor/worker:


How long have you been involved in this church?


If less than one year, what church were you involved in previously?




                                                                                            Revised: 06/18/2007 
PERSONAL INFORMATION (Continued)
Age/year when you accepted Jesus Christ as your personal Lord and Savior:

Baptized in water:     ❑ Yes    ❑ No If yes, when? (Year)


What ministry experiences have you had outside the Church?




Is there anything in your life that might come up as a questionable issue? ❑ Yes     ❑ No
(If yes, please explain)




                                                                                   Revised: 06/18/2007 
FAMILY INFORMATION

Father’s Name:                                                                           ❑Living ❑Deceased
                        Last                       First              M.I


Father’s Address:
                        Number and Street                                              Apt/Suite


City:                                                                   State:                     Zip:


Home Phone:                                 Cell Phone:                                  Fax:


Email Address:


Occupation:                                          Employer:


Mother’s Name:                                                                           ❑Living ❑Deceased
                        Last                       First              M.I


Mother’s Address:
                        Number and Street                                              Apt/Suite


City:                                                                   State:                     Zip:


Home Phone:                                 Cell Phone:                                  Fax:


Email Address:


Occupation:                                          Employer:


I live with (check all that apply)
❑ My Mother ❑ My Father           ❑ A Stepparent           ❑ A Guardian          ❑ On my own ❑ Other:

If you live with a guardian, stepparent or other, please complete the following:

Name:
                        Last                                          First                               M.I


Address:
                        Number and Street                                              Apt/Suite


City:                                                                   State:                     Zip:


Home Phone:                                 Cell Phone:                                  Fax:


Email Address:




                                                                                         Revised: 06/18/2007 
FAMILY INFORMATION (Continued)

Person to contact in case of an emergency (if other than people listed above)

Name:
                       Last                                     First                        M.I


Relationship:                                   Phone:

Briefly describe your family environment:




How does your family feel about you entering PLUGGED IN?




                                                                                Revised: 06/18/2007 
EDUCATION
Are you currently a student (check all that apply)?
❑ No ❑ Full-time ❑ Senior-High School ❑ Freshman-College ❑ Sophomore-College
❑ Part-time ❑ Junior-College ❑ Senior-College


Please list, in chronological order, all high schools, colleges or professional schools that you are
attending or have attended. You must submit an official transcript for each institution you have
attended. You will not need to submit a high school transcript if you have completed 30 or more
college semester credits.


Institution                              City, State, Zip                          Dates of Attendance
(mo/yr)

                                                                                            to

                                                                                            to

                                                                                            to

                                                                                            to

                                                                                            to



Date of High School Graduation (mo/yr):                     Date of College Graduation (mo/yr):

High School GPA:                                            College GPA:



Are you under academic or disciplinary suspension, probation or similar action at any institution?
❑ No ❑ Yes (If yes, please attach an explanation to this application)


If you have not yet attended college, do you plan to earn an undergraduate degree? ❑ Yes ❑ No


What is your intended major(s)?




What are your career goals?




                                                                                    Revised: 06/18/2007 
EDUCATION (Continued)


Colleges or universities to which you are currently applying or have been accepted to:




ACTIVITIES

If you have graduated from high school, please list your activities since graduation chronologically.
Include employment, military service and periods of unemployment.


Activity                                                          Start Date                     End
Date




Have you ever been convicted of a felony? ❑ No ❑ Yes
(If yes, please attach an explanation to this application)




                                                                                  Revised: 06/18/2007 
FINANCIAL
How will you pay for your tuition?

Do you see any reason why you would not have the required tuition fees by the required dates?
❑ Yes ❑ No

If yes, please explain why and how you plan to make your tuition payment:




Do you currently own your own vehicle? ❑ Yes ❑ No

Do you currently have automobile insurance for your vehicle? (required upon entrance) ❑ Yes ❑ No

Name of Insurance Company:                                    Phone:

Policy Number:                                        Agent’s Name:


What current debts, loans, or payments do you have (list amount owed)?




Will these be paid off by the time you enter PLUGGED IN? ❑ Yes ❑ No

If not, how do you plan to make these payments?




                                                                              Revised: 06/18/2007 
EMPLOYMENT

Are you currently employed?      ❑ Yes ❑ No

If yes,   ❑ Full-time   ❑ Part-time         ❑ Seasonal

Place of Employment:

Position:                                           Work Phone:

Work Address:
                        Number and Street                                           Suite


City:                                                             State:              Zip:

How long have you worked there?

Describe your job responsibilities:




Describe your relationship with your supervision and coworkers:




                                                                               Revised: 06/18/2007 
LIFESTYLE

Do you have any physical limitations? ❑ Yes ❑ No     If yes, explain:




Do you smoke? ❑ Yes ❑ No     If yes, explain:




Do you consume alcoholic beverages? ❑ Yes ❑ No       If yes, explain:




Do you or have you ever used any illegal drugs? ❑ Yes ❑ No If yes, explain:




How did you hear about PLUGGED IN?




Why are you applying to be a part of this program?




                                                                              Revised: 06/18/2007 
LIFESTYLE (Continued)

What do you believe God has called you to do with your life?




What is your definition of a servant?




What is your definition of ministry?




What qualities do you think are necessary for a spiritual leader to have?




If you are accepted into PLUGGED IN, are you willing to make a nine month commitment? ❑ Yes ❑ No

Please check any activities that you are interested in participating in at PLUGGED IN:

❑ Missions      ❑ Children’s Ministry   ❑ Worship Band           ❑ Pastoral     ❑ Evangelism

❑ Drama/Theatre         ❑ College Ministry      ❑ Junior High Ministry ❑ High School Ministry

❑ Other:




                                                                                 Revised: 06/18/2007 
REFERENCES
Please give three references (outside of your family) of people who are well acquainted with you:



Reference #1

Name:

Relation:

Phone:                                  Email:




Reference #2

Name:

Relation:

Phone:                                  Email:



Reference #3

Name:

Relation:

Phone:                                  Email:




                                                                                Revised: 06/18/2007 
STATEMENT OF AGREEMENT
The Shekinah PLUGGED IN Internship Program seeks to admit students who will best succeed in and
benefit from a distinctly Christian education, environment and way of life. To accept your appointment
as an intern of PLUGGED IN, you need to be prepared to meet the requirements of the program and,
ultimately, the demands of a lifestyle of servant leadership. As the hope of completing the Great
Commission in your generation becomes more and more of a reality, it is essential that you commit
yourself wholeheartedly to achieving God’s highest purpose for your life. Only through a passionate
and uncompromising obedience to His call will you be able to make a lasting and powerful impact in
the world around you. We will nurture your calling within the program and do our best to help you
fulfill that calling, but ultimately, you alone must decide whether you are willing to pay the cost of
Godliness. The essence of who we choose to be and how we choose to live is embodied in our Core
Values. As an PLUGGED IN intern, you will be expected to abide by these established standards and
guidelines (detailed below), which have been implemented to help you honor God in every area of
your life and to grow spiritually, academically, physically and socially.



CORE VALUES

     1. Hearts fully toward God

     2. Servanthood

     3. Integrity

     4. Character Formation

     5. Passion for the lost

     6. Kingdom Worldview

     7. Spirit of Excellence




My signature affirms my agreement to comply with the core values of PLUGGED IN. I accept the
responsibility of living a lifestyle according to the PLUGGED IN core values.

Signature:                                                         Date:

Printed Name:




                                                                                Revised: 06/18/2007 
ESSAYS

The PLUGGED IN Internship is seeking students who are committed to growing spiritually, who are
well prepared academically and who expect to contribute to their community. We recognize that each
applicant is a uniquely gifted child of God. Your essays help the staff to become better acquainted with
you.


Please respond to both questions as you would to a senior-level English class or college-level
composition assignment. Each response should be 750-1000 words in length, typed and double
spaced. Your responses will receive careful consideration as we make admissions decisions.




QUESTIONS


     1.   Please give your personal testimony and describe your personal relationship with Jesus Christ.
          What does it mean to you to be a follower of Christ?


     2.   Reflect on the scripture passage below. What does this mean to you? Can you connect this
          passage to a recent event or circumstance in your life? How?



          “Therefore, I urge you, brothers, in view of God’s mercy, to offer your bodies as
          living sacrifices, holy and pleasing to God— this is your spiritual act of worship. Do
          not conform any longer to the pattern of this world, but be transformed by the
          renewing of your mind. Then you will be able to test and approve what God’s will is
          — His good, pleasing and perfect will.” Romans 12:1-2 (NIV)




                                                                                  Revised: 06/18/2007 
MEDICAL HISTORY

Name:                                                                Soc. Sec. #:
                 Last                        First       M.I


Date of Birth:                                 Age:                 Gender:         ❑Male ❑Female

Present Address:
                         Number and Street                                          Apt/Suite


City:                                                               State:                      Zip:


Blood Type:                                    Height:               Eye Color:


We need you to complete the following health form, provide a record of your immunizations and have
a physical examination performed by your physician prior to entering the program. Additional
immunizations and medication may be required at a later time for foreign travel. Also, please attach a
copy of your medical insurance/prescription card. All medical information will be kept strictly
confidential and will only be used by PLUGGED IN staff and any relevant insurance providers.



PAST MEDICAL HISTORY

1.   List any serious medical illnesses/injuries you have or have had:




2.   List any operations you have had:




3.   List any serious allergies you have:




                                                                                      Revised: 06/18/2007 
MEDICAL HISTORY (Continued)


MEDICATIONS

1.   List medications taken regularly:




2.   Are you allergic or sensitive to any medicines? If so, please list.




                                                                               Revised: 06/18/2007 
MEDICAL HISTORY (Continued)

IMMUNIZATIONS

               Name       Yes/No             Date Taken

Tetanus

Polio

Measles/Mumps/Rubella

Pneumovax

Influenza

Hepatitis A

Hepatitis B




FAMILY HISTORY

              Condition   Yes/No            If Yes, Explain



High Blood Pressure



Heart Disease



Diabetes



Cancer



Kidney Failure



Alcoholism



Tuberculosis




                                                       Revised: 06/18/2007 
MEDICAL HISTORY (Continued)

Rate your current health:       ❑ Excellent      ❑ Good          ❑ Fair         ❑ Poor


Describe your overall physical condition:




Are there any other illnesses that run in your family?




I certify that the information provided is true, correct and complete to the best of my knowledge,
information and belief.

Signature:                                                        Date:

Printed Name:




                                                                                 Revised: 06/18/2007 
Criminal Record Check Authorization

Today’s Date:

I hereby authorize the Michigan Bureau of Investigation to release any information which pertains to
any record of convictions in its files or in any criminal file maintained on me whether local, state, or
national. I hereby release said Bureau of Investigation from any liability resulting from such
disclosures of this request.



Please Print

Name:                                                                  Soc. Sec. #:
                Last                        First           M.I


Maiden Name:                                         Date of Birth:                    Gender: ❑M ❑F

Present Address:
                        Number and Street                                             Apt/Suite


City:                                                                  State:                     Zip:


Home Phone:                                   Cell Phone:                               Fax:



Print ALL Aliases:

     1.

     2.



Resident of Michigan for          years.

If you have lived in Michigan less than seven (7) years, what other state(s) did you live in?

     1.

     2.



Signature:                                                             Date:


                       After completing this court search record, please return to:
                                      Shekinah Christian Church
                                         Attn: PLUGGED IN
                                            PO Box 2485
                                        Ann Arbor, MI 48106




                                                                                        Revised: 06/18/2007 
PASTORAL RECOMMENDATION FORM

Applicant’s Name:
                                Last                            First                       M.I



Applicants Address:
                       Number and Street                                        Apt/Suite


City:                                                             State:                     Zip:


❑ I waive my rights to review this completed document.


Signature:                                                        Date:


(NOTE: The admission process requires your insight regarding this applicant.)


Thank you in advance for your help. Each PLUGGED IN Intern must submit a pastor’s
recommendation. We are interested in your assessment of this student’s spiritual development.
Serious consideration will be given to your comments; therefore, we ask you to complete this form
carefully. Please comment on the student’s level of commitment to spiritual growth, participation in a
church or organization and potential to contribute to a Christian community, keeping the following
community lifestyle expectations in mind:


The PLUGGED IN Internship seeks to admit students who will thrive in a distinctly Christian
learning community. Members of PLUGGED IN are committed to Christian values and
actively participate in the integration of faith and learning.


If you have any questions, please call 1-734-662-6040.


Name:                                                              Phone:


Name of Church/Christian Organization:


Address:
                       Number and Street                                        Apt/Suite


City:                                                             State:                     Zip:


Email Address:




                                                                                  Revised: 06/18/2007 
PASTORAL RECOMMENDATION FORM (Continued)

How long have you known the applicant?

How well do you know the applicant?        ❑ Very Well     ❑ Well           ❑ Casually

Do you feel the applicant possesses the necessary qualities to succeed in PLUGGED IN? ❑ Yes ❑ No

Do you believe the applicant has a personal relationship with Jesus Christ? ❑ Yes ❑ No

Explain:




1.   To your knowledge, is the applicant’s present conduct consistent with the lifestyle described
     above?

     What evidence have you observed?




2.   Briefly identify the applicant as either an active, average or indifferent participant in the activities
     of the church/organization.




3.   Based on your knowledge of the applicant, would he or she likely profit from the PLUGGED IN
     Internship?




4.   Based on the applicant’s God-given talents and gifts, how do you see him or her specifically
     contributing to the PLUGGED IN Internship?




                                                                                       Revised: 06/18/2007 
PASTORAL RECOMMENDATION FORM (Continued)

Please rank the applicant in the following areas:

                                           Excellent      Above             Average        Below
                                                         Average                          Average


     Emotional Stability



     Leadership Ability



     Peer Relationships



     Spiritual Maturity



     Social Readiness




Comments:




Based on the above information, I     ❑ strongly recommend ❑ recommend ❑ do not recommend
the applicant for admission into PLUGGED IN.

Would you like to discuss the applicant with an admissions staff?       ❑ No     ❑ Yes

Signature:                                                          Date:


                          After completing this recommendation, please return to:
                                         Shekinah Christian Church
                                            Attn: PLUGGED IN
                                               PO Box 2485
                                           Ann Arbor, MI 48106


PLUGGED IN reserves the right to select students on the basis of academic performance and personal
qualifications. PLUGGED IN does not discriminate on the basis of race, gender or national or ethnic
origin in its programs and activities.




                                                                                    Revised: 06/18/2007 
PERSONAL RECOMMENDATION FORM

Applicant’s Name:
                                    Last                        First                       M.I



Applicants Address:
                           Number and Street                                    Apt/Suite


City:                                                             State:                     Zip:


❑ I waive my rights to review this completed document.


Signature:                                                        Date:


(NOTE: The admission process requires your insight regarding this applicant.)


Thank you in advance for your help. Each PLUGGED IN Intern must submit a personal
recommendation. We are interested in your assessment of this student’s spiritual development.
Serious consideration will be given to your comments; therefore, we ask you to complete this form
carefully. Please comment on the student’s level of commitment to spiritual growth, participation in a
church or organization and potential to contribute to a Christian community, keeping the following
community lifestyle expectations in mind:


The PLUGGED IN Internship seeks to admit students who will thrive in a distinctly Christian
learning community. Members of PLUGGED IN are committed to Christian values and
actively participate in the integration of faith and learning.


If you have any questions, please call 1-734-662-6040.


Name:                                                              Phone:


Relation with Applicant:


Address:
                           Number and Street                                    Apt/Suite


City:                                                             State:                     Zip:


Email Address:




                                                                                  Revised: 06/18/2007 
PERSONAL RECOMMENDATION FORM (Continued)

How long have you known the applicant?

How well do you know the applicant?        ❑ Very Well     ❑ Well           ❑ Casually

Do you feel the applicant possesses the necessary qualities to succeed in PLUGGED IN? ❑ Yes ❑ No

Do you believe the applicant has a personal relationship with Jesus Christ? ❑ Yes ❑ No

Explain:




1.   To your knowledge, is the applicant’s present conduct consistent with the lifestyle described
     above?

     What evidence have you observed?




2.   Briefly identify the applicant as either an active, average or indifferent participant in the activities
     of a church/organization.




3.   Based on your knowledge of the applicant, would he or she likely profit from the PLUGGED IN
     Internship?




4.   Based on the applicant’s God-given talents and gifts, how do you see him or her specifically
     contributing to the PLUGGED IN Internship?




                                                                                       Revised: 06/18/2007 
PERSONAL RECOMMENDATION FORM (Continued)

Please rank the applicant in the following areas:

                                           Excellent      Above             Average        Below
                                                         Average                          Average


     Emotional Stability



     Leadership Ability



     Peer Relationships



     Spiritual Maturity



     Social Readiness




Comments:




Based on the above information, I     ❑ strongly recommend ❑ recommend ❑ do not recommend
the applicant for admission into PLUGGED IN.

Would you like to discuss the applicant with an admissions staff?       ❑ No     ❑ Yes

Signature:                                                          Date:


                          After completing this recommendation, please return to:
                                         Shekinah Christian Church
                                            Attn: PLUGGED IN
                                               PO Box 2485
                                           Ann Arbor, MI 48106


PLUGGED IN reserves the right to select students on the basis of academic performance and personal
qualifications. PLUGGED IN does not discriminate on the basis of race, gender or national or ethnic
origin in its programs and activities.




                                                                                    Revised: 06/18/2007 

								
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