Application Form 2019 (2nd Year)

Vital Information

Name*

First Last

Email*

Enter Email Confirm Email

Phone*

(###)###-####

About You

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Personal

Gender*

Male
Female

Marital Status*

Will your spouse be attending school?*

Yes
No

Birth Date*

Age*

Are you a U.S. Citizen?*

Yes
No

Do you attend church regularly?*

Yes
No

Are you a member?*

Yes
No

How long have you been attending regularly there?*

Home Church*

Pastor's Name*

Church Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Have you recently left another church?*

Yes
No

Was it a good parting or are there unresolved issues?*

Health

Please describe any physical or emotional conditions, and state any special attention, treatment, or medication required (if unchanged since last year, enter "same")*

Employment (complete if changed jobs since last year)

Occupation*

Present Employer*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

(###) ###-####

Finances

Will you be prepared to pay REVIVE tuition?*

Tuition is $2,495. Will you be able to pay tuition?

Yes
No

If no, please explain:*

Pastoral Recommendation

If you have changed churches since REVIVE First Year we require an updated Pastoral Recommendation be submitted as part of our application process.

Have you changed churches since REVIVE First Year?*

No
Yes

Pastoral Name*

Pastoral Email Address*

Pastoral Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Payment Information

Please Note*: Upon your acceptance to REVIVE, please complete and electronically submit the Financial Responsibility Form on our web site.

Billing Information

Full Name*

Email Address*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Agreement

I understand that any falsification of information on this application is grounds for dismissal at any time. I hereby certify that the information I have supplied herein is true.

Do you agree?*

By Checking this box You agree to the above statement (Agreement)

Name

This field is for validation purposes and should be left unchanged.