EmailMe Form - IRONWOOD INTERNSHIP APPLICATION

Name *

First Last

Address *

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

Home Phone

### - ### - ####

Mobile *

### - ### - ####

Email *

Birthdate *

MM / DD / YYYY

Country of origin *

Marital Status *

Doctor's Name *

First Last

Doctor's Address *

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

Manitoba Medical # 6-Digit Registration *

Manitoba Medical # 9-Digit Personal *

Medical # from another Province

Medical insurance # if from outside Canada

Any food allergy or sensitivity? *

Any life-threatening allergies? *

Do you carry an epi pen? *

Any medicines you regularly take or conditions we should know about in case of emergency?

Any mobility issues? *

Please share here your personal testimony of salvation *

Please tell us why you have applied to Ironwood and what your expectations are from the course *

Pastor's name *

First Last

Pastor's email *

Personal referee (must have known you 2 years) *

First Last

Referee's email *

Checkbox *

I have read and agree with Ironwoods aims and values at https://ironwoodequipping.ca/internship

I have read and agree with Gateway Church's Statement of Faith at https://gatewaywinnipeg.com/about-us/statement-of-faith/

I would like to finalize my application to Ironwood Internship

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