Application Form 2021 (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 (or small group) regularly?*

Yes
No

How long have you been attending regularly there?*

Home Church (or Small Group)*

Pastor's (or Leader's) Name*

Church (or Small Group) Address*

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

Health

Please describe any physical or emotional conditions, and state any special attention, treatment, or medication required (NOTE: This info is held in strictest confidence and is requested here for the purpose of assisting you in the event of medical emergency.)*

Employment (complete only if changed jobs since last attending REVIVE)

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

Payment Information

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)

Comments

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