Please fill out the following form to provid

PROGRAM

Gender

We run overseas programs each semester based around the average school calendar. Which semester would like to participate?

We have multiple bases that run similar overseas programs. Depending on the semester, some base locations are not going to be available. The following location(s) will be available based on your semester preference.

Please note that due to the uncertainty of international travel, we cannot guarantee location placement. We will take your preference into consideration as much as possible, but ask for your flexibility as well.

Which base location do you prefer?

Unfortunately, your selected program is full! You can either choose to apply for a future semester, select another location, or join our wait list.

Wait listChoose another semester/base

In order to continue your application, please choose a different semester and/or location option above.

In order to submit your information to be on the wait list, click the button below.

BASIC INFORMATION

First Name

Last Name

Middle Name

Goes by (nickname)

Date of Birth (the Cafe 1040 program is intended for 18-29 year olds who are considering a life in missions.)

(mm/dd/yyyy)

Phone Number

### - ### - ####

Email (this will be one of our primary communication methods with you, so it should be the email address you check most often)

Alternate Email (if desired)

Social Media

Facebook Name	Instagram Username
Twitter Handle	Skype Username

ADDRESS

Citizenship

List country of citizenship

European Residents

Are you a current resident of the European Union?

YesNo

We collect personal information to be used in evaluating all applicants to our program. Due to the adventurous and religious nature of our program, this personal information may include: contact information, medical history information, school information, personal history, and personal beliefs, among other things. If you do not feel comfortable filling out this application and freely providing this information, please contact Emily at emily@cafe1040.com

Please also note that at any time during the application process you may request for your information to be removed from our system! If you are not accepted to our program, your application data will be deleted from our system after 4 years.

Best Current Mailing Address

Street Address

Address 2

City

State

Zip

Best Current Mailing Address

Address 1

Address 2

Address 3

City

State/Province

Zip/Postal Code

Country

Passport

***You are required to have a current passport valid 6 months after your RETURN date. If you don't have one or it's expiring soon, start the process of applying for a new one NOW!

Do you have a passport?

YesNo

Do you know the expiration date?

If you don't know, try to find out soon!

EDUCATION

Are you currently in school?

If not in school, what is your status?

High School

Are you interested in receiving college credit for your time overseas with us?

YesNo

College/University

What school?

If you attend Liberty, are you applying to fulfill your Global Studies Internship requirement?

YesNo

Major

Minor, if applicable

When are you planning to graduate?

Please explain.

Do you have any plans after you graduate?

T-Shirt

Do you have a Cafe 1040 t-shirt

YesNo

T-Shirt Size?

PROGRAM DETAILS

Why did you choose Cafe 1040?

What are you hoping to gain from the Cafe 1040 program?

Why do you want to go to North Africa in particular? How do you feel about the heightened security protocol?

Why do you want to go to Europe in particular?

Why do you want to go to the Central Asia location in particular?

Participating in the Cafe 1040 program requires you to raise support. What best describes your perspective on support raising?

OVERSEAS TRAVEL

Please list any overseas experience you have. Include name of country, dates, and purpose of the trip.
Please also include any travel you intend on completing BEFORE your desired semester overseas with Cafe 1040.

BACKGROUND

Have you ever been charged with/arrested for any misdemeanor or felony?

YesNo

Were you ever convicted?

YesNo

Please explain. Include the following details: date(s), charges, conviction, and sentence you received.

WELLNESS

Do you plan to have medical insurance at the time of travel?

Do you have any medical conditions or allergies that could affect wellness? This would include diseases, asthma, broken bones, surgeries, diabetes, etc.

If yes, please describe each condition or allergy and its effect on your wellness in detail.

Are you taking any regular medication?

If yes, please list medication(s) and purpose(s)

Do you ever deal with issues such as eating disorders, addictions, substance abuse, panic attacks, depression, etc. that affects your psychological well-being?

If yes, please describe in detail.

SPIRITUAL

When and how did you become a Christ-follower?

How would you describe your relationship with Jesus?

What is the Gospel?

Church Information

How would you describe your involvement with a local church community?

Name of church

City

State

PERSONAL

How would you describe your personality? Use any of the following questions to inform your answer: What areas of your personal make-up (behavioral patterns, desires, personality, etc.) would you like to grow in? What strengths and talents do you naturally bring to a team? How do you see yourself vs. how others see you?

STATEMENT OF FAITH

The Scriptures // The Bible is the inspired Word of God. In its original languages it is without error. With the help of the Holy Spirit, scripture is understandable to all believers and authoritative in life. God // There is one God who exists in three distinct persons (Father, Son and Holy Spirit). Jesus Christ is the Son of God, eternally begotten of the Father. He became flesh, being born of the Virgin Mary and conceived by the Holy Spirit. He lived a completely sinless life, died on the cross, and was raised to life on the third day. He will personally return to earth to judge the living and the dead. The Holy Spirit proceeds from the Father and the Son and lives within each believer. He regenerates, counsels, convicts, and is the seal of salvation. Mankind // We believe that man was created in the image of God to have fellowship with Him, but became alienated from that relationship through sinful disobedience. As a result, man is totally incapable of restoring right relationship with God by his own effort. Salvation // We believe that the shed blood of Jesus Christ on the cross provides the sole basis for the forgiveness of sins. Therefore, salvation only occurs when a person places their faith in the death and resurrection of Christ as the sufficient payment for their sin. The Church // The church is the body of Christ of which Jesus Christ is the Head. The members are those who have trusted by faith the finished work of Christ. The purpose of the Church is to glorify God by loving Him and by making Him known to a lost world.

I fully agree with Cafe 1040's statement of faith.I do not fully agree with Cafe 1040's statement of faith.

Specifically, why do you not agree with Cafe 1040's statement of faith?

MARITAL STATUS

Marital Status

Anticipated wedding date

mm/dd/yyyy

Wedding Date

mm/dd/yyyy

Name of spouse.

Is the person with whom you are in a relationship also applying?

Is your spouse also applying?

Name of person with whom you are in a relationship.

Please briefly explain, if you think necessary.

Do you have children who would go with you on the Cafe 1040 program?

Children name(s) and birth dates (mm/dd/yyyy).

LIFE STAGE

Please select the option that most closely corresponds to your financial position.

Are either of your parents citizens of the European Union?

YesNo

PARENT INFORMATION

*We will not contact your parents without your permission first.

First Name

Last Name

Spouse First Name, if applicable

Does this parent know that you are inquiring into Cafe 1040?

If no, why not?

What was his/her reaction?

Email Address

Parent Phone

Parent Cell Phone

### - ### - ####

Parent Home Phone

### - ### - ####

Parent Work Phone

### - ### - ####

Alternate Parent Phone, if applicable

Parent Cell Phone

### - ### - ####

Parent Home Phone

### - ### - ####

Parent Work Phone

### - ### - ####

Parent Street Address

Parent Address 2

Parent City

Parent State

Parent Zip

I would like to enter in additional parent information (not listed above)

YesNo

PARENT 2 INFORMATION

Parent 2 First Name

Parent 2 Last Name

Parent 2 Spouse First Name, if applicable

Does this parent know that you are inquiring into Cafe 1040?

If no, why not?

What was his/her reaction?

Parent 2 Email Address

Parent 2 Phone

Parent 2 Cell Phone

### - ### - ####

Parent 2 Home Phone

### - ### - ####

Parent 2 Work Phone

### - ### - ####

Alternate Parent 2 Phone, if applicable

Parent 2 Cell Phone

### - ### - ####

Parent 2 Home Phone

### - ### - ####

Parent 2 Work Phone

### - ### - ####

Parent 2 Street Address

Parent 2 Address 2

Parent 2 City

Parent 2 State

Parent 2 Zip

REFERENCES

Are either of your references citizens of the European Union?

YesNo

REFERENCE 1

We may call a reference during your process to help us determine how to best serve you. This is a person who you consider a personal spiritual mentor, discipler, or pastor.

Reference 1 - First name

Reference 1 - Last name

Reference 1 - Description and length of their relationship with you and/or position in the church, if applicable.

Reference 1 - Best Phone

### - ### - ####

Reference 1 - Best Email

REFERENCE 2

Reference 2 - First name

Reference 2 - Last name

Reference 2 - Description and length of their relationship with you and/or position in the church, if applicable.

Reference 2 - Best Phone

### - ### - ####

Reference 2 - Best Email

Cafe 1040 Current Program Participant	Cafe 1040 Graduate
Cafe 1040 Staff	Cafe1040.com
Camp	Campus Ministry
Church	Internet Search
Missions Agency Referral	Missions Agency Website
Missions Conference	Other
Perspectives	Social Media
University/School

Alex N	Anna T
Avery O	Bri M
Haley J	Jeff M
Justin D	Kate F
Katie B	Kyle S
Robby M	Tess V
Valerie T	Other

Cafe 1040 Current Program Participant	Cafe 1040 Graduate
Cafe 1040 Staff	Cafe1040.com
Camp	Campus Ministry
Church	Internet Search
Missions Agency Referral	Missions Agency Website
Missions Conference	Other
Perspectives	Social Media
University/School