Before You Begin
This application must be completed in one sitting; it cannot be saved. The application should take about 15-20 minutes to complete.

Sections:

• Personal and Trip Information
• Reference Contact Information
• Background Information
• Spiritual Life Questionaire

Trip: You will select your 3 top trip preferences in this application. You can always change these preferences later. Please take a moment to determine your 3 preferences on the trips page.

References: You will need 1 reference: a non-family adult who knows you well.
Please take the time to get their name and phone number ready before continuing with this application.

First Name:

Middle Name:

Last Name:

Cell Phone:

Home Phone:

Email:

Date of Birth:

Anticipated High School Graduation Date:

Legal Guardian Name:

Legal Guardian Email:

Second Legal Guardian Name:

Second Legal Guardian Email:

Please list your trip preferences:

If you are applying as part of a group please enter your Group Code:

In one paragraph, please tell us why you want to participate in an Xtreme Impact trip:

What is your level of interest in Liberty University?

Major/Intended Major:

How Did You Hear About XI?

Gender

Home Church Name:

Other:

Church Reference:
(Pastor, Youth Pastor, or Youth Worker who knows you closely.)

Name:

Phone:

Relationship:

How Long Have They Known You?

Reference:
(Adult non-family member who knows you closely.)

Name:

Phone:

Relationship:

How Long Have They Known You?

Have you ever been convicted of or plead guilty to a crime?

If yes, please explain below:

Have you ever been accused, charged, or alleged to have committed, or have you ever committed any act of neglecting, abusing or molesting any child?

If yes, please explain below:

If yes, please explain below:

Have you ever been treated for a psychiatric disorder?

If yes, please explain below:

Is there any circumstance or pattern in your life that would make it inappropriate for you to serve with minors or would compromise the integrity of Xtreme Impact or Liberty University?

If yes, have you received Christian counseling and/or do you attend a support group?

Have you ever been concerned that you may have an addiction to drugs, alcohol, pornography or any other addiction; or has anyone ever suggested that you may have a problem with any of the above?

If yes, please explain below:

Have you ever voluntarily left or been asked to leave a role within an organization due to a concern regarding inappropriate conduct with minors or adults?

Please share a brief summary of your testimony:

What are your spiritual gifts?

Where are your passions in ministry?

What are your strengths?

What are your weaknesses?

Have you been on previous mission trips?

If yes, where have you traveled on mission trips?

With what organizations have your traveled?

Once you click "Submit Application," your information will be sent to Xtreme Impact.

The Xtreme Impact staff will review your information and notify you via email of your acceptance status within 10 business days. Upon your acceptance, you must submit the $200 Confirmation Deposit to reserve your place on the trip of your choice.

If you have any additional questions, please contact the Xtreme Impact office at 434-592-4999.

How do you plan to raise the funds for your mission trip?