High5 Application High5 Student Application General InformationName* First Last Preferred NameGender*MaleFemaleBirth Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Current Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Cell Phone*Home PhoneEmail* Church InformationName of Church*Name of Pastor*City, State*WebsiteLength of involvement?*ReferencesPlease provide contact information for two references (Church & Academic). They will be sent a reference request:Church Reference Name*Please choose a spiritual leader or pastor who knows you well. First Last Email* Phone*Relationship*Academic Reference Name*Please choose a teacher or academic leader who knows you well. First Last Email* Phone*Relationship*Personal InformationDescribe Your Responsiblities*What types of leadership, volunteer or work responsibilities do you have?How Will You Be Paying for High5?*Family Contact InformationParent or Guardian's Name*Relation to Parent or Guardian*FatherMotherOtherDescribe Your RelationParent or Guardian's Phone*Parent or Guardian's Email* Second Parent or Guardian's NameRelation to Parent or GuardianFatherMotherOtherDescribe Your RelationshipSecond Parent or Guardian's PhoneSecond Parent or Guardian's Email Essay QuestionsEssay Question 1*Talk about faith as it relates to a difficult time you have experienced in your life. Please use at least 250 words.Essay Question 2*How would you describe your relationship with God? Please use at least 250 words.Essay Question 3*What are you passionate about?(And Why)Medical HistoryDuring your time at High5, we will undertake rigorous activities which require that you are healthy. Either complete the information below or submit a recent Doctor's Note or Physical Exam Report as proof of your physical health.List any serious medical illnesses/injuries/operations you have had.*List any allergies:*Do you take any prescription medications? If yes, please list*YesNoPrescription MedicationsAre you allergic or sensitive to any medicines? If yes, please list:*YesNoMedicine AllergiesPhysical Exam I will submit a Physical Exam or Doctor's Note Please submit your physical exam or doctor's note to email@example.com at your earliest convenience. If you have questions, please contact Revolution5 at (719)629-REV5 (7385).Proof of InsuranceWe require each of our students to obtain their own health insurance prior to enrolling. Please submit proof of insurance in the form of a copy of your insurance card or statement. Drop files here or Accepted file types: jpg, gif, png, pdf. Insurance Questions? Not insured? Have questions? Click here so we can follow up with you. Do you have a U.S. Passport?* Yes No It's in the Mail! Statement of AgreementDEVOTION The only sustaining foundation for passion and commitment to the Lord is found in intimacy with Christ; it is the means through which He moves his servants and the glorious reward of those who love Him. DISCIPLINE Practiced discipline forms routines which form guidelines that help to sustain and protect what is most important to us. For this reason we establish disciplines in: Our bodies; through physical training and endurance Our souls (mind/will/emotions); through rigorous study, focused retreats and accountability Our spirits; through prayer, fasting, worship, meditation and constant examining of the Word. CHARACTER We believe that true character is wrought through perseverance and is antecedent to the Message of hope. As Jim Elliot once said, “The quality of the work is determined by the character of the worker.” HONOR Biblical community serves two essential purposes: one, it provides the humus out of which all spiritual growth and maturity take place; and two, it serves as a testimony to the world of those who are in relationship with Jesus. For this, we have cultivated and embody a culture of honor. COURAGE Courage is a reflection of God’s grace given to fulfill God’s purposes through a person’s life.Liability Release I HEREBY ASSUME ALL OF THE RISKS OF PARTICIPATING IN ANY/ALL ACTIVITIES ASSOCIATED WITH Revolution5 Leadership Institute and/or High5, (hereinafter referred to as "Rev5"), of 2621 W. Cucharras, Colorado Springs, Colorado, 80904 and/or use of the property, facilities and services of Rev5, and I agree to the following: I recognize that there are certain inherent risks associated with attending Rev5 and I assume full responsibility for personal injury to myself, and further release and discharge Rev5 for injury, loss or damage arising out of my presence upon the facilities of Rev5, whether caused by the fault of myself, Rev5 or other third parties. I agree to indemnify and defend Rev5 against all claims, causes of action, damages, judgments, costs or expenses, including attorney fees and other litigation costs, which may in any way arise from my use of or presence upon the facilities of Rev5. I agree to pay for all damages to the facilities of Rev5 caused by my negligence, reckless, or willful actions. I certify that I am physically fit, have sufficiently prepared or trained for participation in Rev5, and have not been advised to not participate by a qualified medical professional. I certify that there are no health-related reasons or problems that preclude my participation in this activity. I acknowledge that Rev5 may involve a test of a person's physical and mental limits and carries with it the potential for serious injury, death, and property loss. The risks include, but are not limited to, those caused by terrain, facilities, temperature, weather, condition of participants, equipment, vehicular traffic, lack of hydration, and actions of other people including, but not limited to, participants, volunteers, staff, officers and/or other contributors to Rev5. These risks are not only inherent to participants, but are also present for staff and volunteers. In consideration of my application and permitting me to participate in Rev5, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows: (A) I WAIVE, RELEASE, AND DISCHARGE Rev5, and/or its directors, officers, employees, volunteers, representatives, sponsors, volunteers, teachers or assigns, from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, dangerous or defective equipment or property owned, maintained, or controlled by them, or because of their possible liability without fault, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me, including my traveling to and from Rev5: (B) INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in Rev5, whether caused by the negligence of release or otherwise. I acknowledge that Rev5 and its directors, officers, volunteers, representatives, and agents are NOT responsible for the errors, omissions, acts, or failures to act of any party or entity conducting a specific activity on their behalf. I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness during Rev5. I understand while participating in this activity, I may be photographed. I agree to allow my photo, video, or film likeness to be used for any legitimate purpose by Rev5, its producers, sponsors, and assigns. I agree to observe and obey all posted rules and warnings, and further agree to follow any oral instructions or directions given by Rev5, or the employees, representatives or agents of Rev5. I CERTIFY THAT I HAVE READ THIS DOCUMENT AND THAT I UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A DIGITAL RELEASE OF LIABILITY AND A CONTRACT AND I SIGN IT OF MY OWN FREE WILL. I FURTHER UNDERSTAND THAT BY SUBMITTING THIS DIGITAL RELEASE OF LIABILITY FORM, I VOLUNTARILY SURRENDER CERTAIN LEGAL RIGHTS.Statement of Agreement I understand that my signature represents my agreement with and support of the vision, purpose, and values of Revolution5. I also understand that by completing this form, I am in agreement with the liability release statement above. I certify that the information provided in this application is complete and accurate to the best of my knowledge. I understand that failure to provide accurate and complete information will result in denial of admission.Signature*Printed name serves as your digital signature. First Last Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.