3 years ago

24Seven - Youth with a Mission YWAM Chico

24Seven - Youth with a Mission YWAM Chico

24SEVENAttach a

24SEVENAttach a recentphoto of yourselfherePersonal information (Please Print Clearly)Name: Phone: ( )First Middle LastMailing address:City State ZIP codeSex: Male Female Date of birth: ____/____/________ Age:Month Day YearWeight: lbs. Height: ft. in. T-Shirt size: S M L XL XXLGrade in school:Name of school or employer:E-Mail Address: ____________________@___________________Emergency contact informationName: Home phone: ( )FirstLastAddress:City State ZIP codeRelationship: Father Mother Sibling Relative Other (specify):Work phone: ( )Alternate contactName: Phone: ( )FirstLastRelationship: Father Mother Sibling Relative Other (specify):Page 1 of 8

Family statusFather's name and occupation:First Last OccupationMother's name and occupation:First Last OccupationHow many brothers and sisters do you have? _____ Where do you fit in that number? _____Are your parents Christians? Yes NoAre your parents divorced? Yes No If so, how long? _____ years _____ monthsWho are you currently living with? Father Mother Sibling Relative Other:How does your family feel about you applying for the 24SEVEN program?Health and Personal historyHave you ever had, or do you have, any of the following?Yes No Yes No Yes NoEye trouble Allergies: Dislocated joints Ear trouble Penicillin Head injury Epilepsy Other (specify) Recurrent headaches Asthma Food (specify) Eating disorders Fainting spells Broken bones Anemia Kidney disease Stomach problems Hepatitis Skin condition Diabetes Blood pressure problems Other (please explain):If you answered “yes” on any of the above questions, please explain:Do you have any food allergies?Do you currently drink alcohol? Yes No If “yes”, how long?Do you currently smoke? Yes No If “yes”, how long?Have you ever used drugs? Yes No If “yes”, specify what kind and when you stopped.__Page 2 of 8

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