LCC SMI Application

Application Due Date: March 1, 2010

For printable version, click here.

Name : Date :

Address :

E-mail : Phone :

Emergency Contact

Name :

Address :

E-mail : Phone :

Describe your current educational or vocational status:

Describe your current or past affiliation with LCC, and your current place and frequency of Christian worship:

Name of organization to whom you have been accepted :

Address of organization :

Country Assignment:

Region or City Assignment:

Briefly describe when and how you came to accept the Lord into your life:

General Eligibility (Enter yes or no)

Is your age on March 1 greater than 18 and less than 28 years of age? If yes, enter your birth date:

Do you regularly attend LCC, or have attended LCC regularly in the past if you are an out-of-area student?

Are you a dedicated disciple of Jesus Christ, enjoying consistent Bible reading and quiet times?

Are you seriously considering full-time Christian service as a long-term vocation?

Is your total proposal, including weekly stipend, $15,000 or less?

Do you have any health conditions that would hinder or prevent my participation in the project?

Will you be covered by health insurance during the term of the proposed project?

If yes, provide the name of the health insurance company and policy number:

Project Information

Provide a summary describing the proposed missions work and timeframe (200 words or less):

What is the starting date?

What is the ending date?

How long is the project?

What countries are included in your proposed travel itinerary?

Do all the countries have a favorable relationship with the U.S.? Does the U.S. Department of State (www.travel.state.gov/travel) advise against travel in any of the countries?

List the goals and specific tasks that you hope to accomplish during the project :

Explain how the proposed project fits into the way in which you sense God's leading in your life (200 words or less):

Additional Information Requirements

Please ensure that the following documentation is submitted to the Director of Missions as part of this application:

• Recommendation using the provided form by someone whom you consider to be a mentor or discipler in the Christian faith describing your qualifications to undertake the assignment (provide in sealed envelope). This should not be filled out by a relative.

• If you are currently a student or have graduated from a college or educational program within the 12 months preceding the application due date, please provide a transcript showing a grade point average of 2.5 (or equivalent) or higher.

• A letter of acceptance or confirmation from the organization with which the proposed project is to be carried out.

• Detailed budget proposal using the provided Budget Worksheet.

• Signed personal statement of faith using the provided form.

Project Report

If I am selected as an SMI grantee, I agree to submit a written report about the trip and my experiences to the LCC Director of Missions within 30 days of the project’s ending date. The written report will also include a breakdown of expenses by major category for which the SMI grant was used. Further, I agree to give up to 3 public presentations on the project during the year following the fellowship. This may include a venue during this year’s LCC Missions Conference.

Waiver

If accepted for this trip, I will participate voluntarily and of my own free will. I will not hold the sponsoring missions board, missionaries, or LCC responsible for any accident, injury, illness or other personal loss that might result from this trip. If I am receiving disability benefits, I will provide a letter from a physician stating activities in which I can participate. If I do not have health insurance coverage, I agree to purchase a policy specifically for this trip.

Representation

I attest to the fact that the information provided above and in the accompanying documentation is true to the best of my knowledge.

Signature : Date :