Apply today Life Learner Application First Name Middle Name Last Name Title Miss Ms Mrs Marital Status Email Primary Phone Physical Address City Province Country Current Age Date of Birth Place of Birth Do you have any physical impairments, handicaps, or health conditions which require special attention? Yes No If yes, please describe Do you have a history of emotional instability or psychiatric treatment? Yes No If yes, please describe Do you have any criminal record? Yes No If yes, please describe Do You Have Children Yes No State the Number of Children You Have Do any of your children have any physical impairments, handicaps, or health conditions which require special attention? Yes No If yes, please describe Do any of your children have a history of emotional instability or psychiatric treatment? Yes No If yes, please describe The children to be listed should only be 2 and aged between 1 and 5 Child 1 Male Female Child 2 Male Female Other Children 1 Male Female Other Children 2 Male Female Other Children 3 Male Female Who do you currently live with? Whom should we contact incase of emergency? Name of Secondary School Have you completed G12? Yes No If so, how many points did you obtain? If not, how far did you go? If not, please explain why you dropped out of school State any other education qualification you have Which language are you most confortable with? English Bemba Nyanja Level of English Proficency? Beginner Intermediate Advanced Fluent List skills, gifts and talents you have Do you believe in Jesus Christ? Yes No Have you accepted Jesus as your Lord and Savior? Yes No Which church do you regularly attend? What denomination do you attend or are affiliated with? What ministry are you active in at church? Spiritual Reference Information How did you first hear of Mercy House? Website Social Media Church Friend Northrise University Other...... please explain/specify If other, please explain Explain the reasons that most influenced your decision to apply? What expectations do you have for this program? How would you describe your ability to comprehend? Quick Average Slow What is your attitude towards work I am a harder worker I strive to work hard I lack persistence I never finish anything I start How reliable are you? I meet obligations I neglect obligations I don't know How is your attitude towards money I plan before I spend any money I spend as and when a need arises I am often trusted with money I am careless with money FILE UPLOAD: To Complete this Application, you are required to upload: (1) NRC (2) Recomendation Letter form Church (3) Passport Size Photo (4) G9/G12 Certificate if obtained I do hereby release Mercy House Ministry, its staff, agents, and volunteer assistants from any liability whatsoever arising out of any injury, damage or loss which may be sustained during the course of involvement with the Ministry. I certify that all information in this application is complete and accurate. Submit Application
