2nd Year Student Application Personal InformationName* First Last Preferred NameEmail Address* Enter Email Confirm Email Mobile Telephone*Gender*MaleFemaleDate of Birth* Date Format: MM slash DD slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Marital Status*SingleMarriedSeparatedDivorcedWidowedName of Spouse or FiancéDate of Marriage Date Format: MM slash DD slash YYYY Number of ChildrenEmploymentCompany Name*Start Date* Date Format: MM slash DD slash YYYY Location*Role / Title*Will you continue working during the school year?*FinancesHow do you plan to pay the financial obligation of tuition?*What percentage of tuition do you currently have?*Please enter a number from 0 to 100.Will you be applying for a payment plan?*YesNoIf you do not have the full amount for tuition, how do you plan to raise the funds needed to fulfill the financial obligation of tuition?*If you would like to apply for a scholarship, please fill in this application form with the application fee then send an email to hssmadmin@harvestnetintl.comPlease include your name, date of application and the motivation for applying for a scholarship.HealthIn the case of a medical emergency what is the name and contact number of a close family member or friend?*What is your relationship to this person?*Do you have a physical disability? If yes, please describe*Have you ever received a diagnosis of any disease or cancer? If so, please describe*Have you ever been treated, or been recommended to receive treatment, for any mental or emotional condition? If so, please describePlease list any medications you are currently taking and for what purpose*Please list any allergies to food, medicine, etc*Medical Insurance Provider*Policy #*Phone NumberOther than a toll free number, if possibleHow would you describe your temperament?* Church HistoryHome Congregation*Pastor's Name*List the name of the church that your membership is presently recorded.*List the names of other churches you have regularly attended in the past five years.*Give a general summary of the ministries you have been involved in for the past five years.*Give a general summary of the areas of service outside the church in which you have been involved.*Why are you applying for the 2nd year program?*What are some of your personal expectations and goals for the year?*Applicant's StatementI, the undersigned, verify that to the best of my knowledge, the information contained in this application is correct. If in the evaluation of the Senior Pastor, it would be considered advisable to secure additional input from the church(es) listed, I hereby authorize such action and verify that I have read HNI’s child protection policy. I understand that background checks will be done to affirm that the information is correct.SignatureDate Date Format: MM slash DD slash YYYY Application Fee*Application Fee $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
