Please take a few minutes
to fill out this survey. The information will help us to promote
and fund our programs and stay in touch with you. Thank you.
First Name:
Last Name:
Middle Initial:
Name while in program, if different:
Current Address:
Current City:
Current State:
Current Zip:
Home Phone:
Work Phone:
Cell Phone:
Email Address:
Date of Birth (mm/dd/yr):
Program
(Click all that apply):
Global Intern
International Intern
International Young Adult Volunteer
Mission Co-Worker
Mission Diaconal Worker
National Young Adult Volunteer
Reconciliation & Mission
Mission Volunteer USA/Summer Service USA
Young Adult Intern
First Placement Site City/Country
(i.e. Cincinnati, Ghana, etc.):
Dates of Service:
From
of
to
of
Second Placement Site City/Country
(i.e. Cincinnati, Ghana, etc.):
Dates of Service:
From
of
to
of
Third Placement Site City/Country
(i.e. Cincinnati, Ghana, etc.):
Dates of Service:
From
of
to
of
How did you first learn about
the Program' (Please be specific):
Education
Since participating in the program,
I:
Attended or currently am attending
seminary.
No
Yes
If yes, where'
Attended or currently am attending
graduate school.
No
Yes
If yes, where'
Work
(Please list most significant
or most recent positions in all of the following categories that
apply.)
Worked or am working as a pastor
or on a local church staff.
No
Yes
If yes, what is/was your most
recent position title'
What is/was the name of your employer'
Worked or am working as middle
governing body or other church institution staff.
No
Yes
If yes, what is/was your most
recent position title'
What is/was the name of your employer'
Worked or am working as General
Assembly Council (national) staff'
No
Yes
If yes, what is/was your most
recent position title'
What is/was the name of your employer'
Worked or am working in a seminary
or religion department in higher education.
No
Yes
If yes, what is/was your most
recent position title'
What is/was the name of your employer'
Worked or am working for a non-profit
or social service agency.
No
Yes
If yes, what is/was your most
recent position title'
What is/was the name of your employer'
Volunteer Service:
Since participating in the program,
I:
Volunteered or am volunteering
within ecumenical bodies.
No
Yes
If yes, what is/was your most
recent position title'
What is/was the name of the organization'
Volunteered or am volunteering
in a church or church-based ministry.
No
Yes
If yes, what is/was your most
recent position title'
What is/was the name of church
or ministry'
Volunteered or am volunteering
for a non-profit organization.
No
Yes
If yes, what is/was your most
recent position title'
What is/was the name of the organization'
Was actively engaged or am actively
engaged in advocacy work/issues'
No
Yes
If yes, what is/was your most
recent role'
For what issue(s) have you been
an advocate'
Church Membership
Was a member of or am currently
a member of a local church (or presbytery if a minister).
No
Yes
What is/was the name of your church'
We are excited about the possiblitiliy
of your continued involvement in the life of various mission service
programs, including the Young Adult Volunteer program. Please
indicate all of the following opportunities in which your would
be willing to participate:
Mission recruitment
Mission promotion/interpretation (speaking)
Support of current volunteers
Serve as a facilitator/small group leader
for mission service event (placement, orientation, etc.)
Connect to alumni in your area
Advocacy for mission programs
Other:
Please share how your involvement
in the mission service programs of the PC(USA) have informed your
sense of vocation, affected your career/schooling choices, impacted
your faith, or transformed your life in other ways. We would like
to share your story with the broader church. Please let us know
if you do not wish for us to share your reflections:
Thank you for taking the time to
fill out this survey. We would love to stay connected to you!
By giving us your contact information, we can let you know about
upcoming conferences, alumni gatherings, send you newsletters,
and contact you when we will be hosting events in your area. We
will also be sending out an updated online directory to all alums.
If you do not wish to be included in this directory, please let
us know.
