Revolution5 Student Application

Step 1 of 6 - General Information

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General Information
I plan to enter Revolution5:
Name
First Last
Preferred Name
Gender
- Male
- Female
Birthdate
Date Format: MM slash DD slash YYYY
Current Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cell Phone
Home Phone
Email
Permanent Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Are you a U.S. citizen?
- Yes
- No
If no, what is your U.S. immigration status?
Church Information
Name of Church
Name of Pastor
City
State
Website
How long have you been involved with this church?
References
Please provide contact information for two staff from this church who know you. They will be sent a reference request:
Name of First Reference
First Last
Email
Phone
Relationship
Name of Second Reference
First Last
Email
Phone
Relationship
Personal Information
How will you pay for your tuition?
Will you be bringing a car with you to Revolution5?
- Yes
- No
Here are recommendations for your vehicle
Colorado's mountainous terrain and weather conditions can catch some drivers by surprise. Here are some things to keep in mind.
- Make sure you have decent tread on tires
- Windshield cracks tend to expand
- Basic fluid check: oil change, windshield fluid, etc.
Are you currently employed?
- Yes
- No
Employed
- Full time
- Part time
Place of Employment
Position
Work Phone
Length of Employment
Describe Your Responsiblities
Please check all that apply to your current educational status:
- Not a student
- Full-time
- Part-time
- High School Senior
- College Freshman
- College Sophomore
- College Junior
- College Senior
Please list, in chronological order, all educational institutions you have or are currently attending:
Institution
City, State, Zip
Dates of Attendance
Institution
City, State, Zip
Dates of Attendance
Institution
City, State, Zip
Dates of Attendance
Institution
City, State, Zip
Dates of Attendance
Date of high school graduation (mo/yr)
Date of college graduation (mo/yr)
H.S. GPA
College GPA
ACT Score
SAT Score
Are you currently under any academic or disciplinary suspension, probation, or similar action at any institution?
- Yes
- No
If you have not yet attended college, do you intend to pursue an undergraduate degree?
- Yes
- No
Please explain:
Do you have an intended major, if so what might you study?
Do you have any intended career goals, if so what are some of them?
Colleges or Universities to which you are currently applying:
Please list any school, church, or community activities or groups with which you are currently, or have been previously involved.
Family Background
Father's Name
- Living
- Deceased
Father's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Work Phone
Email
Mother's Name
- Living
- Deceased
Mother's Address
- Same as Father's
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Work Phone
Email
I live with:
(Check all that apply)
- Father
- Mother
- Stepparent
- Guardian
- On My Own
- Other
Person to contact in case of emergency:
Name
Relationship
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Work Phone
Briefly describe your family environment:
How does your family feel about you entering Revolution5:
How did you hear about Revolution5
If accepted, what do you hope to gain from your time at Revolution5?
Who are some people who you consider servant leaders, why?
Please give three personal references who are well acquainted with you. [may not be mentioned elsewhere in this application and may not be family members]
Name
Phone
Relationship
Name
Phone
Relationship
Name
Phone
Relationship

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Essay Questions
Essay Question 1
Talk about a difficult time you have recently experienced in your life. How was your faith instrumental in bringing you through this time? What was an aspect of the Lord’s character that you experienced during this time? How has this experience changed your daily walk with the Lord?
Essay Question 2
Imagine for a moment that you are a believer in the first century church. For weeks a man by the name of Paul, called an apostle, has been teaching on the basic truths of what has come to be called “Christianity”. Paul is planning to leave shortly and has asked a few key individuals to help circulate his teachings to the surrounding provinces. You have been chosen: it is a high honor. You are about to enter your first city, in particular, one that has never before heard about Jesus. Using several short excerpts from Paul’s various letters, how would you present a compelling explanation about the Gospel message of Jesus Christ.
Video Introduction

We believe one of the best ways to get to know someone is by getting to see them in their environment. Its that Idea of a picture being worth a thousand words.
Objectives for the video:
1. Introduce yourself. Tell us your name, age, where you work, year in school, hobbies, passions, something God has been teaching you recently and why you think you are a good fit for Revolution5.
2. Give us a tour of your house. We would love to see where you live.
3. Introduce us to your family. We would love to meet your parents and siblings.
Video Type*
- Upload File
- Link to File
- Email File
Video File*
Only MP4 videos, with h.264 encoding.
Use Handbrake to convert your videos.
If that seems too hard or if you are running into issues feel free to choose the link to file option.
Accepted file types: mp4.
Link to File or Insert Embed Code*
You can upload your video to Youtube or Vimeo and then paste the url or embed code here. This is the best option for long videos and videos that are high pixel quality resulting in a large file sizes.
Email us at admissions@rev5.org with the video attached.
In the subject area tell us that this is a video introduction and include your name.
e.g. (Video Introduction - John Smith)

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Medical History
List any serious medical illnesses/injuries/operations you have had.
List any allergies:
Do you take any prescription medications? If yes, please list
- Yes
- No
Prescription Medications
Are you allergic or sensitive to any medicines? If yes, please list:
- Yes
- No
Medicine Allergies
Have you ever engaged in any addictive behaviors (i.e. drugs, excessive alcohol, etc.)?
- Yes
- No
Immunizations
Have you had any immunizations listed below? If yes, please list which immunizations and the date: Tetanus Polio Measles/Mumps/Rubella Pneumovax Influenza Hepatitis A Hepatitis B Hepatitis C
Family History
Has anyone in your family been diagnosed with any of the below conditions? If you please list who and how severe. High Blood Pressure, Heart Disease, Diabetes, Cancer, Kidney Failure, Mental Illness, Alcoholism, Tuberculosis
Are there any other illnesses that run in your family? If yes, please list:
- Yes
- No
Other Illnesses
Proof of Insurance
We 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.

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Statement of Agreement
DEVOTION
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.”

COMMUNITY
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.

COURAGE
Courage is a reflection of God’s grace given to fulfill God’s purposes through a person’s life.
I HEREBY ASSUME ALL OF THE RISKS OF PARTICIPATING IN ANY/ALL ACTIVITIES ASSOCIATED WITH Revolution5 Leadership Institute, (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

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Background Check
Due to our community living environment, it is required by law that we run a background check on each student.
Signature
Printed full name serves as digital signature
First Last
Email
Year Married
Print Maiden Name
Date of Birth
Place of Birth
Social Security Number
Driver's License Number
State
Current Local Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Is this is a Cell Phone?
- Yes
- No
If you haven't lived in Colorado or have for LESS than 3 years, please fill in the following, beginning with the most recent STATE you lived in before moving to Colorado and ending with the STATE you lived in 10 years ago.
Start and End Dates
Last Name
Last name during this time
Address
City, State, Zip, Country

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Make a payment
You will be asked to fill out your payment information on the following page.
Price: $50.00
Coupon
Total
$0.00
Have a unique payment situation? Save the form and send us an email so we can help! Contact Us

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info@rev5.org
(719)629-REV5(7385)

Contact Us

P.O. Box 6473
Colorado Springs, CO 80934

Step 1 of 6 - General Information

General Information

Church Information

References

Personal Information

Family Background

Essay Questions

Video Introduction

Medical History

Statement of Agreement

Statement of Agreement

Background Check