Titus Online Application Form

PERSONAL DETAILS

Name: (as found in passport)

Family/Surname

Legal First Name

Middle Name

Preferred Name

PERMANENT ADDRESS

Street Address

City

State/Province

Post/Zip Code

Country

CONTACT INFORMATION

Mobile

E-mail:

BIRTH DETAILS

Birth Date (day/spell month/year)

Age:

Country of Birth:

PASSPORT DETAILS

Passport Number:

Expiry Date:

Place of issue:

CITIZENSHIP

Are you Australian or New Zealand citizen?

YesNo

Emergency Contact Name:

Emergency Contact Relationship to you:

Emergency Contact Number:

Emergency Contact Email:

Personal History

Please prayerfully and concisely answer the following questions.

Describe your expectations of this Titus Project. State your reasons for applying. What is your ultimate purpose upon completion?

Having considered the daily commitment, are you willing to invest the necessary time and study to complete this course?

Do you plan to pursue a University of the Nations degree at this time?

Do you have any difficult situations to deal with in regard to attending the Titus Project? How can we pray for you?

Financial Responsibility

Payments Overview. All fees are in Australian dollars (AUD).

First payment	$40 non-refundable application fee	due with application
Second	$800 Lecture Fees	due 3 weeks after acceptance

Release of Liability

I do hereby release Youth with a Mission INC, 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 Youth with a Mission.

YES

Consent for Burial

I agree that, in the case of my death while with Youth with a Mission, Youth with a Mission may carry out the burial in the place of the deceased. If my family desires to have my body shipped home, my family will pay for it. I hereby absolve Youth with a Mission and all its staff and associates of any burial costs.

YES

Chicken Pox	Measles (Rubella)	Measles (Rubeola)	Mumps	Pertussis
Scarlet Fever	Tuberculosis	Hepatitis	AIDS/HIV

Titus Online Application Form

Personal History

Financial Responsibility

PART A. Personal Details and Medical History