Our Mission- To show the love of Jesus to those affected by HIV/AIDS around the globe.

Youth With A Mission Kansas/New Jerusalem Missions
 

Thank you for applying online for the HIV/AIDS Short Course. 

  1. Fill the online application out completely and submit

  2. Print two reference forms to be mailed in

  3. Send a recent photo with application, through e-mail, or postal service

Please select which HIV/AIDS Short Course you would like to attend.

Wichita, Kansas  Dates: To Be Announced  Durban, South Africa  Dates: July

Download Application  ||  Download Reference
     
General Information:
    
       
First Name:
 Last Name:
 Middle Name: Preferred Name:
       
Street Address:
City:
 State:
 Zip Code:
     
Country:
     
       
Home Phone:
 Work:
 Cell:
  
       
E-mail:
    
       
Date of Birth:
  		 Age:
Sex:
 
       
Marital Status:
    
       
Please Choose:
 		Date: (other than single)
 		  
       
Spouses Full Name:
 Date of Birth:
       
Number of Children accompanying you:
Ages:
 0-2 3-5 6-10 11-13 14-16 17-18
       
Church Status:
    
       
Church Name:
 How long have you attended:
 years
       
Pastors Name:
 Denomination:
       
Church Address:
 Church E-mail:
       
Church Phone:
 Church Website:
       
Emergency Contact:    
       
Full Name:
 Relationship to you:
       
Address:
    
       
Home Phone:
 Work:
 Cell:
  
       
References: (pastor/mentor or friend)

Please print and give out two references

    
       
Full Name:
    
       
Address:
    
       
Home Phone:
 Work:
 Cell
  
       
Full Name:
    
       
Address:
    
       
Home Phone:
 Work:
 Cell
  
       
  

New Jerusalem Missions  209 E. Broadway  Newton, KS  67114 USA  Phone: 316-282-2101 or 316-283-7711

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