2027 Preceptorship Application

First name:*
Last name:*
First name you go by:*
Female or male?*
- Female
- Male
Birthdate:*
MM slash DD slash YYYY
Marital status:*
- Single
- Married
- Divorced
- Separated
How did you hear about the preceptorship?*
References:
Two references are required with your application. Your application will be complete once we receive your references.

References can be completed online. Please send the appropriate link to your reference and ask them to complete it.

Reference for Pastor/Christian vocational worker: Pastor or Christian Vocational Worker Reference Questionnaire

Reference for Friend: Peer Reference Questionnaire

Your address:*
Street Address City State / Province / Region ZIP / Postal Code Country
Cell phone:*
Email:*
I will be at the above address til:
MM slash DD slash YYYY
Time at address:
- I will be at this address indefinitely

Parent's full names:*
Parent's address:*
Street Address City State / Province / Region ZIP / Postal Code Country
Mother's cell phone:
Father's cell phone:

Citizenship:*
- US
If not U.S., do you have a VISA?
- Yes
- No
What type of VISA?

Requested Absences - June 13 - July 11, 2027:
Due to the nature of this program, any absences from the preceptorship must first be pre-approved by the directors. Please make any request for absence here and include the reason.

What is the denomination of the church you attend at home?
What is the denomination of the church you attend at school?
With which campus ministries have you been involved?
How long?
- Less than one year
- 1-2 years
- 2-3 years
- 3-4 years
- More than 4 years
- Not actively involved
Have you been a regular participant in a small group Bible study?*
- Yes
- No
What type of group? How long in each?
Do you hold a regular position in your campus ministry? If so, which one?
What part do you plan to play in your campus ministry next year?

List your specific reasons for believing God is leading you to the preceptorship.*
Specify your objective(s) for this summer, both for yourself and your ministry.*
What, in your opinion, are your strengths and abilities?*
What areas need development or attention?*
Have you discussed your desire to attend the preceptorship with your parents? If married, how does your spouse feel about your applying for this? Is your spouse interested in accompanying you to the preceptorship?*
(Spouses are welcome! Spouses who have attended in the past have been very pleased.)
Describe your future career plans for integrating your Christian faith into your practice and patient care.*
Do you have any dietary restrictions or allergies? Please explain.*
Do you have any significant health issues, physical imitations or disabilities that may affect your ability to participate fully in the mission or would require accommodation in order to take part?*
Do you receive any on-going medical treatments?*
If you take any medications, will you be able to have enough for the duration of the mission?*
In the last year have you used narcotics, hallucinogens, drugs or tobacco products not prescribed by a physician?*
Do you have or have you had any psychological/emotional conditions or struggles? (Examples: depression, phobia, suicidal thoughts, significant anxiety, bipolar disorder, etc.?*
In the last year have you struggled with an eating disorder?*
In the last year have you self-harmed? (ex: cutting/burning yourself)*
Do you know other students applying to the preceptorship? If so, who and what is your relationship to them?*

APPLICATIONS ARE AVAILABLE FOR 2027

2027 Preceptorship - June 13 - July 11, 2027

Applications are processed upon receipt of application and references.

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