Name:

Mailing Address:

Permanent Address
(if different):

Daytime Phone:

Evening Phone:

Email Address:

Date of Birth:

Gender:

Country of Citizenship:

Have you been to Koinonia before? (please enter dates):

Emergency contact name:

Relationship:

Phone Number:

Requested Term (select one):

Requested Year (select one):

Physical, medical, and/or dietary requests
(including vegetarian)

Life Experiences: Please tell us about yourself, what has happened in your life that has shaped who you are, and what has led you to get involved at Koinonia. Please also remark on your spiritual journey.

Work Experiences and Interests: Please discuss your educational and/or work experiences. Do you have particular skills or interest in certain areas of work at Koinonia?

Family: If any family members (e.g., partner, spouse, children) would come with you for this intern term, please give names, ages, and relationships. (Each adult should also fill out his or her own application.)

References: Please list the names and contact information (phone number, email address, and/or mailing address) of two references that we may contact (supervisors, teachers, clergy).