First Name: *

Last Name: *

Email Address: *

Home Address: *

City/Suburb: *

State/Territory: * -- Please Select -- ACT QLD NSW NT SA TAS VIC WA

Postcode: *

Primary Contact Phone Number: *

Gender: * -- Please Select -- Male Female

Date of Birth (DD/MM/YYYY): *

Age:

Which STUMP are you applying for?: * -- Please Select -- Sydney STUMP April 2012 (Sunday 15th - Saturday 21st) Sydney STUMP July 2012 (Sunday 8th - Saturday 14th) Sydney STUMP September 2012 (Sunday 23rd - Saturday 29th) Brisbane STUMP September 2012 (Tuesday 25th - Saturday 29th)

Emergency Contact Name: *

Relationship to you:

Best Contactable Phone Number: *

Medicare Number (if applicable):

Healthcare Card Number:

Name of Medical Fund:

Contribution Number:

Do you belong to an ambulance fund?: Yes No

Family Doctor:

Phone:

Address:

Do you have any pre-existing medical conditions?: Yes No

If yes please specify:

Name and dosage of any medications that must be taken:

Please specify any allergies we need to be aware of:

Explain in 25 words or less what you expect to do at STUMP?: *

Have you ever been on a mission trip/experience before?: *

Why would you like to take part in this mission experience?: *

Are you a Christian? If yes, what's your testimony? If not are you comfortable participating in a Salvation Army program which operates primarily from a Christian worldview?: *

Are you actively involved in church/ hobbies/ sports/ music/ justice groups? If so how much and explain your involvement?: *

How did you hear about STUMP and the Edify program?: *

Please indicate the contact details of the people you have selected to be a referee for your application. Referee #1: *

Please indicate the contact details of the people you have selected to be a referee for your application. Referee #2: *

If applicable please include the contact details for two people who will pray for you during/before STUMP: