Full Name: *

Name You Go By:

Gender: * Male Female

DOB:

(MM/DD/YYYY)

Address:*

City:*

State: * Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming

Zip: *

Telephone:* - -

(###) - ### - ####

Email: *

School/Employer Name: *

Class/Grad Date:

(MM/DD/YYYY)

Program: * Allied Health Dentistry Medicine Nursing Pre-Med Other

Parent(s) Name:

Parent(s) Address:

Parent(s) Phone: - -

(###) - ### - ####

Home Church:

Pastor:

Member?: Yes No

Home Church Address:

Current Church:

Pastor:

Member?: Yes No

Current Church Address:

Are you proficient in Spanish?: * Yes No

Do you have a valid passport?: * Yes No

Passport #: *

Past participants have described the SMI as “the hardest summer you’ll ever love.” Whether it’s the heat, community living, recognition of sin, or being burdened by others’ needs, you undoubtedly will be challenged this summer. The SMI provides intensive training in the context of real life experience. In light of this:

Are you willing to submit to God’s process of developing you in character and discipline?: * Yes No

Are you willing to learn how to communicate Jesus Christ and the Gospel to others?: * Yes No

Are you willing to be involved in intensive study and application of the Bible?: * Yes No

Are you willing to participate fully in all scheduled project activities?: * Yes No

If your parents play a significant role in this decision, have you discussed the SMI with your parent(s)? If so, what was their response? (800 char limit)

How did you hear about the SMI as an opportunity for your summer? (800 char limit)

Briefly describe the history of your faith journey with God (800 char limit):

What is your life vision or calling as you know it to be at this point? (800 char limit)

How do you envision your future career? Please be as specific as you can at the present time (800 char limit):

Explain why you want to participate in the SMI this year (800 char limit):

Due to the nature of this project, absences are limited to school or family, or if you are IN a wedding. It must be approved by SMI directors. Please make your request here for any days between July 2-31, 2011 that you need to be away (800 char limit):

For Your Information

1. All applications are subject to approval by the SMI Applications committee.

2. Please have your letters of recommendation sent directly to our office by 3/25/11. The personal rec. should be someone who knows you well and can comment on the benefits of your participation in the SMI. This could be a Bible study leader, pastor, close friend, SMI alum, etc. The professional rec. should be someone who is familiar with your calling and abilities in the health professions. This could be a dean, professor, pre-med advisor, mentor in your field, family friend, etc.

3. Acceptance notices will be sent out no later than 4/6/11.

4. Applying does not commit you to the SMI. If accepted, you must then return a confirmation form by April 15 to reserve your place.

IMPORTANT. PLEASE READ THIS PAGE BEFORE YOU SUBMIT:

What a person believes is the foundation for both life and ministry. The following are Christian tenets to which the SMI leadership ascribes. If you disagree with any of these, please explain your differences.

1. The Bible is the inspired, infallible, inerrant Word of God. (2 Tim. 3:15-17)

2. There is one God, eternally existent in three persons: Father, Son and Holy Spirit. (John 10:30)

3. These are central truths of the Christian faith: The deity of our Lord Jesus Christ, His virgin birth, His sinless life, His miracles, His vicarious and atoning death through His shed blood, His bodily resurrection, His ascension to the right hand of the Father, and His personal return in power and glory. (Jn 1:1-5; Phil. 2:5-11, 1 Cor 15:1-6)

4. Believing in the person and work of Jesus Christ alone results in salvation; Jesus Christ is the only way of salvation. (Titus 3:4-7; Eph. 2:8-9; John 14:6; Acts 4:12)

5. The Holy Spirit's present ministry and indwelling enables the Christian to live in fellowship with God. (Gal. 5:16-23; I John 1:3-4)
   
   Comments (800 char limit):
   

The commitment of the Summer Medical Institute is “to serve and not to be served.” Serving in ministry means you sometimes submit to the needs of others even in areas of biblical freedom. Paul is a model of this (Romans 14 – 15:6). Serving with the SMI means you agree to the following:

1. I am willing to set aside personal preferences, habits and schedules to fulfill the ministry of the SMI.

2. I understand there are variations in practice and understanding of Scripture in some areas of Christian living. In serving with SMI, I will abide by the standards of the SMI in all areas including dress, entertainment, activities, etc. This includes a willing agreement to abstain from the use of alcohol, drugs, and tobacco for the duration of the SMI, and being sensitive to cultural, regional, church and SMI expectations and standards. See the enclosed "Policies and Procedures" page for a description of SMI expectations and standards.

3. I will seek to provide excellent medical care to God’s glory and to present Jesus Christ as Lord and Savior.

4. If accepted to the SMI, I am willing to raise support for my participation, trusting God for His provision with a target goal of $2,300.00. I acknowledge that God is sovereign and He shall supply all of our needs according to His glorious riches in Christ Jesus.

5. I have read the SMI application and accept its provisions and agree to live, work and serve in accordance with them. I, also realize that in accepting a term of volunteer service, it is with the clear understanding that SMI does not assume responsibility for loss of my property, damage to the same, personal harm or illness that may come to those who travel with me or myself. I, for myself, my heirs, executors, administrators and assigns, in consideration of my admission to volunteer service and other good and valuable considerations, do hereby release and forever discharge the Summer Medical Institute, the Valley Baptist Health System, the Valley Baptist Family Practice Residency and the Rio Grande Valley Medical Missions from liability for any claim or demand that I or my heirs, executors, administrators or assigns might otherwise assert upon the basis of any of the foregoing. In volunteering, I recognize that I do not become an agent or employee of SMI in rendering my services and I agree to hold the Summer Medical Institute harmless from any claim that might arise out of any acts performed by me while serving as an SMI volunteer.
   
   Accept