Break the Grey

Register
Fees
Review
Finish

We are so excited to begin this mission of changing lives with you. You are about to embark on the greatest journey of your life! 
 
Must be High School graduate or GED equivalent to age (24) to attend Break the Grey Internship. Questions? Call Anna Pranger at 260-409-8321 or email her at interndirectorbtg@gmail.com
 
The information in the FIRST section is requested to comply with federal guidelines and will not be used to determine admission status
 
* Denotes a required field to fill in

SECTION 1:

First Name*
Last Name*
Email*
Verify Email*
Phone Number*
Date of Birth:  DD/MM/YYYY*
Personal Facebook Link*
Instagram Handle*

Address*
Address Line 1 
Address Line 2 
City     State     Zip 
Country*

Gender*
Male
Female
Marital Status*

U.S Citizenship *
Yes
No
If you are not a U.S Citizen, please tell where you are from?

Ethnic Orgin*

Are you a veterans dependent?*
Yes
No

Are you in the National Guard or Reserves?*
Yes
No

Will you be receiveing VA benefits?*
Yes
No

SECTION 2:

Which internship session are you applying for?*
January 2019-July 2019
August 2019-May 2020

Date of salvation?  mm/dd/yyyy*

Have you been baptized in water?*
Yes
No
If yes, when?

Home church?*
Youth Pastor/Leaders name?
Senior Pastor's name?
List any ministries you are/have been involved with?

Reference 1 name, Address, Relationship, & Phone Number? *
Reference 2 name, Address, Relationship, & Phone Number? *
Reference 3 name, Address, Relationship, & Phone Number? *

Last High School Attended*
Type of School*

Graduated?*
Yes
No
If yes, when?  mm/dd/yyyy
If no, anticipated graduation date?  mm/dd/yyyy

Do you have a GED?*
Yes
No
Are you or have you ever been under an IEP(Individual Educational Plan) or a 504? Please attach in email and send to interndirectorbtg@gmail.com. The contents of the form will remain confidential.*
Yes
No

ACT or SAT score?*
If you haven't taken one, do you plan to?*
Yes
No
List any school honors, awards, and accomplishments

Are you employed?*
Yes
No
Present Employer
Position
Hired When?
Past Employer
Position
Hired When?
Reason for leaving?

Father's Name*
Father's Address*
Father's Phone Number*
Father's Occupation*
Accepted Christ?*
Yes
No

Mother's Name*
Mother's Address*
Mother's Phone Number*
Mother's Occupation*
Accepted Christ?*
Yes
No

How do you plan to pay your internship tuiton of $6,000?*
Do you own your own vehicle?*
Yes
No

How would you describe your health?*
List any allergies you may have
List any physical limitations
List any current medication you currently use
List any other physical problems or ailments

SECTION 3:

Have you used illegal drugs?*
Yes
No
Date of last use?  mm/dd/yyyy

Tobacco Use?*
Yes
No
Date of last use?  mm/dd/yyyy

Alcohol use?*
Yes
No
Date of last use?  mm/dd/yyyy

If you have been charged or convicted with a felony please explain below
Have you ever been involved in satanic worship or other occult practices?*
Yes
No
If so, please explain?

Fighting *
Fearfulness*
Insomnia *
Inability to concentrate*
Laziness/Lack of motivation*
Lying*
Learning Disablities *
Nervous Disorders*
Pornography*
Problems with socal relationships*
Problems with parents*
Night terrors*
Reading comprehension*
Sadness *
Stress*
Sexually promiscuous lifestyle*
Suicide attempts *
Theft *
Thoughts of suicide*
Trouble making decisions *
Unstable job record*
Participated in non traditional marriage(without a marriage license)*
Trouble listening to authority figures*

If you answered "Past Issue" or "Current Issue" above please explain to the best of your ability what you have come to learn about the issues you faced.*

In the space provided, please give us a little of your backround(minimum of 250 words please)*

I THE ABOVE APPLICANT GIVE MY APPROVAL.


Acceptance:* 
Full Name:* 
You have reached the end of your application process. We are very excited about the possibility of working with you on the upcoming tours & outreaches. Click the submit button below and proceed to the payment page in order for your application to be finalized.
 
Break the Grey reserves the right to refuse an application at anytime. If Break the Grey refuses an application, applicants will be offered a refund.