Successful Relationships inc.

Christian Student Leadership Project Application

All fields are required

Student Information

First Name

Last Name

Email Address

Address

City

State

Zip

Home Phone

School

Grade

Graduation Date

Gender

Male
Female

Date of Birth

Extracurricular Activities

Do You Work?

Yes
No

If Yes, How many
hours per week?

1-3
4-6
5-7
8+

List Activities
Involved at church

Average Hours Spent
Weekly at Church

1-3
4-6
5-7
8+

Any Mission Work?

Yes
No

List Any Other
Activities You Are
Involved In

Average Hours Spent
Weekly On these
Activities

1-3
4-6
5-7
8+

List any Leadership
Roles You've Held

Please Give a Brief
Testimony of Your
Christian Walk

Church Information

Church Name

Address

City

State

Zip

Phone

Number of Years
Attended

1-3
4-6
5-7
8+

Teaching Pastor

Youth Pastor

Personal References

Reference #1

Name
Phone

Reference #2

Name
Phone

Reference #3

Name
Phone

Reference #4

Name
Phone

Reference #5

Name
Phone

Essay

Using the prompt:
Why Should you be selected for this project? How do you feel that it will impact
you and your community?
Please write an essay and upload it to attach with your application.