Project Timothy Southwest

Project Timothy Southwest

Everything except payment is included in this form! This form includes your (1) application, (2) liability waiver, and (3) a place for you to select someone to do your recommendation. Once you have completed the form a link will be emailed to you for paying the $250.
Your Information
Name *

First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Email *
example@example.com
Cell Phone *

Area Code Phone Number
Age *
Birthdate *

Month Day Year
Date Date Picker Icon
Gender? *
What is your T shirt size? *
What year are you applying for? *
Are you currently a leader at your youth group? *
Do you commit to paying the $250 fee if you are accepted? *
To attend Project Timothy, you need to commit to serving at your Youth Group in some capacity for the next year. Do you commit to doing this? *
Are you vegan or vegetarian? *
Please list any food allergies. *
Have you ever been convicted of a crime? *
Have you ever been convicted or accused of child abuse/sexual abuse or been involved in any activities related to molesting/abusing a child or a youth? *
Please upload your short essay on why you want to come to Project Timothy. *

Browse Files

Cancel of
Your Parent's Information
Name (please indicate one parent for contact purposes) *

First Name Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number
Church Information
Church Name *
Senior Pastor *

First Name Last Name
Youth Pastor *

First Name Last Name
Email for the pastor who will fill out your recommendation form. *
example@example.com
Medical Waiver/Liability Form

This section is to be completed by a parent or guardian for applicants under 18.
Allergies *
Medications *
Doctor's Name and Phone *
Other Information
Insurance Company *
Policy Number *
Subscriber Name *
Group Name or Number *
I, as parent/legal guardian of the minor(s), understand that my child will be attending Project Timothy at The Vineyard Gilbert in Gilbert AZ. I understand that during this time he/she will be accompanied by volunteers from this and other Vineyards in our region under the direction of staff and volunteers from the Southwest Region of the Vineyard and The Vineyard Gilbert.

I hereby release The Vineyard Gilbert, as well as any other Vineyard church who provides volunteer staff, their staff and volunteers, and any sponsors of the event, from responsibility and liability for any loss, injury, or illness that my child may sustain during any activity. In the event of an emergency, I understand that every reasonable effort to contact me will be made. In the event that I am unable to be contacted, I hereby authorize an adult leader, as agent for me, to consent to any medical, dental, or surgical diagnosis; X-ray examination; and/or hospital care advised and supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of the state or province where the services are rendered, either at the doctor's office or in any hospital.
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary. *

Agree
Electronic Signature *

Clear
Date *

Month Day Year
Date Date Picker Icon
Click to let us know you aren't a robot! *
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Project Timothy Southwest

Your Information

Your Parent's Information

Church Information

Medical Waiver/Liability Form