Options Intern Application

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Fields

Options Intern Application

General Information

Name*

First Name*

Last Name*

Date of Birth*

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Month

Day

Year

Current Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Permanent Address (if different from current)

Address Line 1

Address Line 2

City

State

ZIP Code

Social Security Number

For XXXX purposes

T-Shirt Size

Small Medium Large XL 2XL 3XL

Phone*

Is this a cell phone?

Yes No

Email*

Education and Work Information

High School*

Graduation Year*

College/Trade School

Current Year in College

Freshman Sophomore Junior Senior Graduate

Degree/Major

Graduation Year

Other Education

(ex. Seminary, Bible College, Masters Program)

Are you a citizen of the United States?*

Yes No

If no, are you authorized to work in the U.S.?

Yes No

Date that you are available to begin internship*

Current Work Status

Full-time Part-time Student Only

Employer

Occupation

Work Phone

May we contact your employer as a reference?

Yes No

Employer Address

Address Line 1

Address Line 2

City

State

ZIP Code

Emergency Contact Information

Name*

First Name*

Last Name*

Relationship*

Phone*

Medical and Liability Release

Medical Insurance Company

Policy

Primary Care Physician

The essential functions of this position require walking long distances, being on your feet for more than five hours per day, and active participation in physical activities such as swimming and other sports. Will you be able to meet these physical requirements of this position?

Yes No

Allergies, Health Concerns, Activity Restrictions: Please list all that may apply

EMERGENCY MEDICAL AND LIABILITY RELEASE: My signature indicates that in the event of an emergency and in the event that: (1) a parent/legal guardian or the Authorized/Designated Individual identified above cannot be reached; or (2) immediate medical attention is necessary, I consent to have Urban Impact Foundation [UIF] staff/leaders/volunteers act in my behalf and hereby grant my permission for emergency treatment to be administered until a parent/legal guardian or the Authorized/Designated Individual identified above can be reached.I am consenting to any X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to his authorization.I agree not to hold Urban Impact Foundation, The Pittsburgh Public Schools, partnering organizations or any staff/leaders/volunteers, liable for any decisions for any emergency medical treatment made under this authorization or for any accident or loss to the student however caused. In addition, I do hereby release, forever discharge and agree to hold harmless Urban Impact Foundation, The Pittsburgh Public Schools, The City of Pittsburgh, partnering organizations, and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the child-participant that occur while said child is participating in the above described trip or activity.

I agree to the above I do not agree

PROMOTIONAL RELEASE: I also release UIF to use photos, video and audio of myself in promotional materials that support Urban Impact Foundation & its programs. I understand photos may be used on billboards, bus stop advertisements, and online social media like Facebook. I release UIF from any liability connected with the use of my picture or voice recording as part of any promotional recruitment or fundraising program.

I agree to the above I do not agree

Signature

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URBAN MINISTRY INFORMATION

Do you have a first aid or CPR certificate?*

Yes No

What is the date of expiration?

Have you ever participated in an Urban Impact program?*

Yes No

Which program(s)?

How did you learn about Urban Impact?*

Have you ever served in an urban ministry?*

Yes No

How and where did you serve?

If you were hired, would you be able to commute to work or would you need housing in Pittsburgh?*

I don't need housing and I can commute I need housing and I don't have a car I need housing but I do have a car I have housing but I don't have a car Unsure at this time

Other: Other Value

Have you ever done fundraising for a mission trip, job, or internship?*

Yes, I have. No, I never have.

Other: Other Value

This internship is paid, but fundraising/support raising is a required part of the internship.

Employment/Ministry Experience

At the end of this section, you will be asked to attach your resume. If there is any information you would like to add to your resume, please use the section below.

What experience have you had involving Middle or High School students?*

Preferred age group*

Middle School High School No Preference

Jobs/Experiences where you have worked with children (include jobs from above, if applicable). Include ages or grades of children.*

Do you have any other experiences that align with the internship you selected?*

Please attach a resume below that includes any of your performance, experience, and/or job history.*

No File Chosen

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Background Information

Have you ever been convicted of a crime?*

Yes No

Explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation

Applicant's Statement

I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be helpful in arriving at an employment decision. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with Urban Impact Foundation is of an “at will” nature, which means that the employee may resign at any time and the employer may discharge the employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized representative of Urban Impact Foundation. In the event of employment, I understand that false or misleading information provided in my application or interview(s) may result in discharge whenever discovered. I understand, also, that I am required to abide by all policies and procedures set forth by Urban Impact Foundation, and that these policies and procedures are subject to change without notice. I hereby release any and all former employers and references from any liability for releasing information about me. I certify that if selected to work in camp and sign a letter of commitment, that I consider my signature binding.

I agree to the above I do not agree

Please sign to certify agreement to the Applicant's Statement above.*

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ORGANIZATIONAL DOCTRINE OF URBAN IMPACT

At Urban Impact Foundation (UIF) we believe everyone is in process with the Lord. Our understanding of God is one of those areas we are constantly growing in. We are interested in where you are on your journey.

Please read the following beliefs about God which UIF affirms. After reading, please respond with yes, no, or somewhat. If there are areas of difference, please clarify in the spaces allowed.

ABOUT THE SCRIPTURES: We believe the entire Bible is the inspired Word of God and that men were moved by the Spirit of God to write the very words of Scripture. Therefore, we believe the Bible is without error in its original manuscripts.

My beliefs are consistent with the UIF statement regarding the Scriptures*

Yes No Somewhat

Please clarify your differences with our statement about the Scriptures

ABOUT GOD: We believe in one God who exists in three distinct persons: Father, Son, and Holy Spirit.

My beliefs are consistent with the UIF statement regarding God*

Yes No Somewhat

Please clarify your differences with our statement about God

ABOUT JESUS: We believe that Jesus Christ is fully God and fully human. We believe that he was born of a virgin. We believe that He lived a sinless life. We believe that His miracles were true. We also believe that He died in the place of sinners on a cross, that He was truly resurrected, and ascended back to heaven.

My beliefs are consistent with the UIF statement regarding Jesus*

Yes No Somewhat

Please clarify your differences with our statement about Jesus

ABOUT THE HOLY SPIRIT: We believe in the personality and deity of the Holy Spirit. We believe He gives life, He sanctifies, He empowers and comforts all believers. We believe that it is through the power of the Holy Spirit that we are born again, and that the work of the Spirit includes convicting us of sin and empowering us to be righteous.

My beliefs are consistent with the UIF statement regarding the Holy Spirit*

Yes No Somewhat

Please clarify your differences with our statement about the Holy Spirit

ABOUT MANKIND: We believe that mankind was created in the image of God. God gave Adam, the first man, specific commands that were to be obeyed. Through his sinful disobedience to these commands, Adam and the whole human race were alienated from God. As a result, man is incapable of regaining a right relationship with God through his own effort.

My beliefs are consistent with the UIF statement regarding Mankind*

Yes No Somewhat

Please clarify your differences with our statement about Mankind

ABOUT SALVATION: We believe that, as a result of The Fall, all men are lost and separated from God because of sin. For this reason, we believe that man is saved only through repentance and faith in the finished word of Christ. Therefore, in order to experience salvation, even those who have never heard the name of Jesus Christ must hear of Christ and understand who He is to be saved. We believe that, when we repent and express faith in this manner, we are declared not guilty before God by His grace alone, are born again, receive the gift of eternal life, and become children of God.

My beliefs are consistent with the UIF statement regarding Salvation*

Yes No Somewhat

Please clarify your differences with our statement about Salvation

ABOUT THE CHURCH: We believe the Church is the body of Jesus Christ, and it is composed of all true believers, with Christ as the Head of the body. We believe that, while on earth, believers must join themselves to other Christians in visible local assemblies. We believe these local assemblies are also the Church, for it is in these local assemblies that the work of the Churcch is carried out. The present work of the Church is the worship of God, the loving and teaching of people, and making Him known to a lost world. We believe the purpose of the Church is to glorify God.

My beliefs are consistent with the UIF statement regarding the Church*

Yes No Somewhat

Please clarify your differences with our statement about the Church

ABOUT CHRIST'S RETURN: We believe in the personal and bodily return of the Lord Jesus Christ. His return will complete and establish the ongoing enjoyments of our salvation in His glorious Kingdom.

My beliefs are consistent with the UIF statement regarding about Christ's Return*

Yes No Somewhat

Please clarify your differences with our statement about Christ's Return

Spiritual Journey

Please share about how you came to know Jesus Christ as your Lord and Savior.*

Please share briefly about your family and upbringing.*

Describe recent areas of recognized growth in your day-to-day Christian life*

What church do you attend?*

(ex. Allegheny Center Alliance Church - Pittsburgh, PA)

Do you have an accountability partner or mentor in your life? If yes, why is that relationship significant to you?*

As representatives of Christ, we are urged in Ephesians 4:1 to "live a life worthy of [our] calling." This includes resisting lifestyles and temptations that our society may deem acceptable. What decisions have you made in supporting living a life honoring God?

Share how you set boundaries to honor God and live above reproach.*

Personal Evaluation

Please list your top 3 to 5 Spiritual Gifts and/or Natural Abilities*

Into what career or ministry do you sense God is leading you?*

In what ways would a summer position with Urban Impact help you prepare for this career/ministry?*

Please share why you would like to intern with Urban Impact.*

Skills: Do you have experience doing the following? If yes, please explain the context (years of involvement, location, group).

Leading Worship*

Yes No

Leading Worship - Years & Context

Teaching Bible Lessons/Studies*

Yes No

Teaching Bible Lessons - Years & Context

Playing/Coaching Sports*

Yes No

Playing/Coaching - Years & Context

Arts: Dancing, Acting, Music, Visual Arts*

Yes No

Arts - Years & Context

Tutoring Students*

Yes No

Tutoring - Years & Context

Organizing and Leading Group Games/Activities*

Yes No

Group Games - Years & Context

Teaching Math or Literacy*

Yes No

Teaching - Years & Context

List your hobbies (things outside of work/school that you do for fun).*

References

Please list two references we can contact. One reference must be a pastor/spiritual mentor and the other reference must be an instructor/director.

Reference A - Pastor/Spiritual Mentor*

First Name*

Last Name*

Reference A - Phone Number*

Reference A - Email*

Are they your pastor or spiritual mentor?*

Pastor Spiritual Mentor

How long have you known Reference A?*

Reference B - Instructor/Director*

First Name*

Last Name*

Reference B - Phone Number*

Reference B - Email*

Are they your instructor or director?*

Instructor Director

How long have you known Reference B?*