Personal Information

Your First Name *

Your Last Name *

Recent Photo

Sex *

Male

Female

Age *

Birthdate * +

Marital Status *

Email *

Phone Number *

Current Address *

City *

State *

Country *

Zip Code *

Permanent Address (If different from current address). Type N/A if both addresses are the same. *

Country of Birth *

Country of Citizenship *

Name as listed on passport *

City and country where passport was issued *

Passport Number *

Passport Expiration * +

Do you have a visa to visit the United States? *

Yes

No

Visa Number *

Issue Date * +

City and Country Where Issued *

Visa Expiration * +

Have you Ever Been Denied a Passport or Visa? *

Yes

No

Please List the Nation and Details of Refusal *

Have you ever been convicted, imprisoned, or been on probation or parole? *

Yes

No

When and Where? Please explain the details. *

Have you ever been indicted or convicted of a sexual crime? *

Yes

No

When and Where? Please explain. *

What is your first language (Mother tongue)? *

What other languages do you speak? *

Education

Levels Completed *

Have you ever studied English? *

Yes

No

Level of English study completed. *

Where did you study English? *

How long did you study English? *

Have you ever been involved in Youth With A Mission Before? *

Yes

No

Please list the YWAM schools or other programs you've been a part of. *

Supplemental Question

How did you hear about our ESL program? *

Friend

Website

Former Student

Other

How did you hear about our ESL? *

What are your main purposes for coming to the United States? *

What is your purpose for coming to the U.S.? *

How long do you plan to be in the United States? *

Why do you want to learn conversational English? *

Why do you want to learn English? *

What are your expectations for this course? *

Are you able to pay for the training? *

Yes

No

What are your plans to pay for your training? *

What are your plans after ESL school is over? *

Do you have any health or special needs we should know about? *

Do you go to church in your country? *

Yes

No

Church Name *

YWAM’s mission is to ‘Know God and Make Him Known’. What is your experience with God? *

Acknowledgment of Responsibility:
I understand that payment of the required school tuition fees must be made in U.S. currency prior to or upon my
arrival. Further, I agree to meet in a timely manner, prior to the completion of school, all expenses incurred during
my involvement with Youth With A Mission and University of the Nations. If I am accepted, I will abide by the spirit, rules, and schedule of the school.

Please sign your name below *

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Date * +

Emergency Information

Emergency Contact *

Relationship to you *

Emergency contact's phone number *

Emergency contact's e-mail *

Emergency contact's full address *

Consent for Treatment:
In case of emergency, I/we hereby agree to the performance of such treatment, including anesthesia and surgery,
as the attending doctor or physician may deem necessary.

Your Signature *

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Date * +

Certification:
I certify that all the information in this application and its supplements is complete and accurate.

Your Signature *

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Today's Date * +