Baptist College for

World Evangelism

 

Training

For the Field

On the Field

 

“…that the world through him might be saved.”

John 3:17

 

 

 

 

 

 

General Information

 

            The Baptist College for World Evangelism was started with one purpose in mind: to help churches and colleges build stronger and more effective missions programs.

            With the help of many veteran missionaries and the cooperation of pastors from around the world, the Baptist College for World Evangelism is uniquely qualified to equip students for a lifetime of productive ministry.

            Although the college is located in Peru, South America, it is not exclusively for students who are considering a ministry in a Spanish-speaking country.  The Baptist College for World Evangelism is a place for any dedicated Christian who has a heart for souls and a desire to learn.

            Through Biblical methods and practical training, our students learn to adapt to other cultures, how to raise support, and how to build independent Baptist churches wherever the Lord may send them.  Many students have graduated from this program and are now working effectively in ministries at home and around the world.

 

            Stateside Address                    Sending Church Address                     Field Address

            W. Austin Gardner                  Whitfield Baptist Church                     Casilla 1677

            P.O. Box 519                          2134 Dug Gap Road                           Arequipa, Peru

            Braselton, GA  30517             Dalton, GA  30720                             South America

 

 

Contact Information

Phone:  865-803-3867

E-mail: [email protected]

 

 

Steps to Becoming a Student in the BCWE

 

1.      Make sure you meet the requirements (see below).

2.      Fill out the Application Form (page 11) and email it to [email protected] or mail it to the following address:

Travis Snode

209 Bald Cypress Drive

Clover, SC  29710

 

3.      Once you are notified that you are approved, you will need to have your pastor complete the Pastor Recommendation Form (page 12) and mail it to the address above.

4.      Sign the Covenant (page 13-14) and mail it to the address above.

5.      Begin the process of raising your money.

6.      Purchase a plane ticket or have us buy one for you.  (Let us know if you need us to do so.)

7.      Apply for a passport 6-8 weeks prior to your departure.

 

 

 

 

 

Requirements

 

To enroll in the BCWE, you must:

 

  1. Be saved and baptized.
  2. Be 16 years or older.
  3. Have your parent’s permission.
  4. Have a pastor’s recommendation.
  5. Know that it is God’s will.
  6. Have enough money:
    1. For your plane ticket, which will cost about $1000 (Approximately)  $1000
    2. For your monthly expenses of $700/mon. ($700 x 6 mon = $4200)   $4200
    3. For a personal cell phone which costs $25/mon (Optional)                 $150

(Includes meals, lodging, and $100 of personal spending money.)

Total for 6 months = Plane Ticket + Monthly Expenses + Phone =       $5350

  1. Be willing to abide by the rules and regulations that apply to this college.
  2. Fill out an application and have it approved.
  3. Sign the covenant that applies to this college.
  4. Want to attend and see God do a work in your life.
  5. Get a passport.

 

 

 

 

 

 

 

 

Rules & Regulations

 

WEATHER


            Arequipa has spring and fall-like weather all year long.  For this reason, you will need to bring light weight clothing for the day and heavier clothing for the evening.  Temperatures range from 45 at night to 75 during the day.  It will be cool during the church services and in the house at night because neither our churches nor our homes have any heat. 

 

DRESS CODE

 

            The missionaries in Peru are in the process of training their people to live holy and separate Christian lives.  For this reason, all students in the BCWE need to set a good example for their people.  Keep in mind that though you will have the opportunity to do many tourist activities, the college is much more than a tourist trip—it is leadership training. 
 

All students must abide by the following dress code while in Peru:

 

Men

1.      Need to wear dress pants or causal pants (Dockers, khakis), dress shirt, and tie for all services and classes. (A suit coat that can be packed without excessive wrinkling is good, but it is not required.)

2.      Can wear causal pants or nice jeans for most out of class and church activities.

3.      Can wear a casual polo shirt or T-shirt for most out of class and church activities.

4.      Will not be permitted to wear the following items at any time:  shorts, tank tops, cut-offs, bandannas, sandals, torn clothing, distasteful clothing, or immodest clothing.

5.      Must not come out of the privacy of their own room without their shirt on.

6.      Are not permitted to have any type of body piercing.

7.      Should keep in consideration when packing that the church benches are not padded and the streets are very dusty.  This may have an effect on what clothes you choose to bring.

 

Ladies

1.      Need to wear a dress or skirts/blouse for all church services and classes.

2.      Can only wear culottes for certain activities, such as horse-back riding, which will be according to the missionaries’ discretion.  When they do wear them, they must be the type that look like a dress or skirt when worn (not walking shorts or “Baptist pants”).

3.      Must wear skirts or dresses that do not have hems or splits that are above four inches below the knee when sitting down.

4.      Will not be permitted to wear the following items: pants, shorts, tank tops, sandals, midriff tops, spaghetti straps, sweat pants, wind suits, revealing clothing, spandex or lycra, sleeveless clothing, torn clothing, distasteful clothing, immodest clothing.

5.      Are not permitted to have any type of visible body piercing other than their earlobes.

6.      Should keep in consideration when packing that the church benches are not padded and the streets are very dusty.  This may have an effect on what clothes you choose to bring.

 

SAFETY

            Though Peru is a very safe place to stay, it is a third world country, and like America, accidents can happen.  If some basic guidelines are followed and authorities are listened to, no harm, however, other than normal sicknesses that result from living in a foreign country, should result.

Here a few things to keep in mind:

1.      You are not required to get vaccine shots, but you can check with the Health Department to see what shots are recommended.

2.      You should not drink water from the tap.  You will need to drink only bottled water or filtered water that will be provided in your home.

3.      You need to be careful to watch your things while on the trip or in town.  Like most big cities, Arequipa has pickpockets and thieves, especially around the airport. Do not wear excessive amounts of jewelry, etc., and do not flash your money around.

4.      If you want to find out what the US government says about travel to Peru, you can go to the following webpage:  http://travel.state.gov/peru.html

 

CULTURAL DOS AND DON’TS

  1. Don’t treat their church any differently than you would a church in the United States. Their church is just as good, and many times much more spiritual than a church in the US.
  2. Don't treat national pastors any differently than you would a pastor in the United States.
  3. Don’t eat or drink in front of them without offering them something.
  4. Don’t constantly criticize their country or talk about your country and all that you miss there or how it is better, etc.
  5. Don’t turn your nose up at their food. Develop a taste for their foods.  Eat with them. 
  6. Don’t skit church stay outside during church services, but rather get involved in the services.

7.      Look at things like they do.  They aren't strange or new—you are.

SPENDING MONEY
            You will need to take some money to buy food and snacks on the way down to and back from Peru.  Once you get to Peru, we will give you $100/month of the money that you raised.  If you want more than $100 to buy souvenirs, snacks, extra film, postcards, and other miscellaneous items that you think you will need while you are in Peru, then you will need to take that with you or raise the extra support.  You can exchange your American money for Peruvian money once in Peru.

            (You will have the option to get a cell phone which will enable you to call all the missionaries in Peru, receive any call from the States, or receive any other call.  The phone gives you 180 minutes of calling time to any land-line phone in Peru and 20 minutes of calling time to any cell phone in Peru.  If you want this phone, you will need to raise $25 extra per month to pay for it.)

 

LUGGAGE

            You will be permitted to bring two checked baggage items, one carry-on, and one personal item.  Each checked bag should be less than 70 pounds and should not exceed 62” (length + height + width) limits. 

            Your carry-on should have approximate dimensions of 22" x 14" x 9" and should weigh less than 40 pounds.  Your personal item can be one of the following items:  a purse, a briefcase, a laptop/computer (all laptop/computers must be carried aboard and cannot be checked), a camera case, or an item of similar or smaller size.

            Your name needs to be on every piece of luggage.  All baggage is subject to being searched; therefore, you need to always have the keys to any locked luggage readily available.

PACKING

Remember to pack the following items:

            -  King James Bible and notebook for messages

            -  1960 Reina Velara Spanish Bible

            -  Sun screen (highest strength possible)

            -  Spanish-English Dictionary (optional)

            -  Journal or diary

            -  Spare pens

            -  Clothes and shoes for church

            -  Battery-powered alarm clock

            -  Camera, film, and batteries

            -  Prescription medicines

            -  Personal First Aid Kit containing: cold tablets, Tylenol, Band-Aids, Kaopectate,                                      hydrocortisone cream, etc.

            -  Only necessary credit cards

            -  Toiletries

            -  Spare eyeglasses

            -  Sun glasses

            -  Flip flops or house shoes

            -  Snacks that are durable to pack (i.e. Granola bars, candy bars, etc.)

            -  Pictures of family, church, etc.

            -  Light weight jacket or sweater

     -  Good walking shoes

Do not pack the following items in your checked luggage:

            -  Your passport
            -  Money
            -  Needed medications
            -  Anything valuable

Remember to place the following items in your carry-on:

            -  Passport

            -  Photo ID & any student ID that you have (Will help you get discounts at certain places.)

            -  Bible

            -  Journal/Notebook

            -  Ink pen

            -  Tickets

            -  Camera

            -  Itinerary

            -  Luggage Keys

            -  Needed medications

     -  Change of clothing in case your luggage is lost in transit or arrives later than you do!

Do not bring the following items:

            -  Radio, Walk-mans, etc.

            -  Video games

            -  Pocket knives

            -  Worldly magazines

            -  Excessive books (The missionaries have many good books that you can read.)

            -  Contemporary Christian/Rock Music.  (Please do not bring any music that has a distinctive beat.  Only bring conservative Christian  

                Music.)

Other packing tips:
           
1.  Always carry prescription medications in their original pharmacy-supplied bottle.  If the medication you are taking is a narcotic,

                carry a letter of explanation from yourdoctor.
            2.  Do not pack anything in your suitcase that has the batteries installed.
            3.  Do not take anything you do not need.  Leave valuables at home.  Go through your wallet or purse and purge them of credit cards

                and items you will not need in Peru.
            4.  Pack liquids in a sealable plastic bag before placing them in your suitcase.
            5.  Avoid taking patterned outfits in favor of neutral solid colors that you can mix and match.  This will help you to not have to pack

                so many clothes.
            6.  Place your heaviest items at the bottom of your suitcase, separating the layers with tissue paper or plastic dry-cleaning bags.
            7.  Use brightly colored string, duct tape, or anything to mark the outside of your luggage so that it is easily recognized when picking it

                up at the carousel.

 

LAUNDRY

            You will be responsible for doing your own laundry just as if you were in a college in the States.  You will not need to bring detergent, etc. with you because you can purchase these items in Peru.

 

CLASSES

            You will have four to eight hours of class almost every day that you are not traveling, and you will earn 30 hours of college credit that are transferable to many Bible Colleges in the United States.  The classes include:  Missionary Methods, Catholic Evangelism, Church Planting Seminar, Indigenous Missions, Cultural Adaptation, Cross Cultural Ministry, History of Missions, Leadership Training, Issues in Missiology, Comparative World Religions, Prayer and Spiritual Warfare, and Spanish.  You will be required to participate in all classes, as well as in language school sessions, churches services, and anything else that the missionaries may ask of you.

 

PREACHING IN SERVICES
            At different times and in different churches, those who are called of God to preach will have a chance to preach.  Everyone, even those who are not called to preach, will have the opportunity to give a word of testimony.  The missionaries will tell you how much time you have to preach, teach, or testify.

 

Guidelines for giving your testimony

1.      Write out your testimony.  It will surprise you how easy it is to get sidetracked by all the commotion and translating.

2.      Keep it brief (about 3 minutes), because with translation, 3 minutes will turn into 5!

3.      Open with a greeting in Spanish.  The folks like it when you try to speak their language and show a genuine interest in them.

4.      Tell who you are, a little bit about yourself, such as something about your family, etc.

5.      Add a couple of positive statements about the country, the church, and the people!do not talk about the poverty of the area, the currency as funny money, how sorry you feel for them, etc.  Tell what Christ has done for you, how you got saved, how you realized your need of a Savior, how your life has changed since salvation, how Christ helped you lately, etc.

6.      Give a verse and make sure to give the application.

Guidelines for giving your testimony (continued)

7.      Do not give graphic details about your sin or your past life.

8.      Avoid slang and idioms in your testimony.  They can be very difficult to translate and may have no meaning in Spanish.

9.      Do not use extremely long or extremely short sentences.  Give a good thought that can be easily remembered by the translator!

10.  Avoid stressing your material success or blessings and especially making any comparisons to what the people have in the country you are visiting!

11.  Avoid speaking of the sacrifice that you made to get to the field.  Remember what it cost you to get to the country may be several months of a working man's income.  You may share with them the blessing of being able to come and how good God was to answer your prayers and make it possible to be there!

12.  Don't tell jokes or humorous stories without prior approval to make sure that they translate.

13.  Thank the folks again and ask them to pray for you.  Be excited about the country and the pportunity to be there.

 

JOURNAL KEEPING

One of the best things you can do to remember your time in Peru is to keep a journal!

      It is…

            A Diary of your daily thoughts and events

            A record of your prayer requests 

      A record of how you felt in Peru

      A way to preserve your joy for future memories

      A list of what you are learning and how God is working in your life

      A booklet of quotes and sayings that you hear that are a blessing for you

      A way to review your day with God

      A help as you share with your family, friends and church all that God did in your life.

What are some tips on keeping a journal?

1.      What did I learn today that will benefit my spiritual life?

2.      What areas of my life does God seem to be talking to me about right now?

3.      What did I learn about serving Him?

4.      What did we do today?

5.      Who did we meet today?

6.      What decision did you make today for your spiritual life and growth?

 

LODGING

      You will be staying in a house that is separate from the missionaries’ homes, but close enough to ensure that they can assist you with any problem you may have, supervise you, and teach you.  The guys and girls will have separate dormitories, and carefully supervision will be in effect to prevent any inappropriate behavior.  Students will not be permitted to initiate or seek new romantic relationships with other students during my time in Peru.  All actions which might be perceived as amorous attentions toward indigenous people will not be tolerated.

 

HISTORY OF THE WORK

 

In January of 1988 the Austin Gardner family arrived in Peru.  After finishing all the paper work and arriving in Arequipa they began working in the Hunter church.  This church had been started by Missionary Mike Fester, who was then with ABWE.  The church had a small rented room at Avenida Berlin 730.  The Gardners began to learn about the culture and how to work in Peru.  In January of 1989 they began what would become the Peru Bible College or Seminario Bautista Independiente del Sur (literally the Independent Baptist Bible College of the South.)

In the later part of 1988 Julio Panduro, national missionary, and Austin Gardner started the church in Mariano Melgar.  After working there for about one year the Mike Scott, Maranatha Baptist Missions, family arrived and the church was turned over to him.

During this same time period we were able to purchase some land out in the agriculture town of Pedregal, Majes.  A work was begun there.  Chris Gardner and several of the Peruvian brethren stayed there and helped get this work started.  It was at this time that Apolinario Bedregal, who had begun the work in Belaunde, stated that he would be interested in taking the work in Majes.  Therefore we took over the work in Belaunde and gave him the work in Majes.

We then started the work in Bolognesi.  On Sundays, Austin Gardner would go first to Bolognesi at 8 am with a national and preach there.  At 9 am he would leave there and go to Belaunde where another national brother had already began the service and preach there.  At 10 am another national brother would begin the services in Hunter and I would arrive there about 10:30 to 11 am to preach in the morning service.  Then at 4 pm we would return to Bolognesi at 6 pm to Belaunde and then at 7:30 to Hunter.  On Wednesday night I would alternate preaching in Bolognesi or Belaunde and then on Thursday night we would have the service in Hunter.

In June of 1989 we organized the Hunter Baptist Church while our pastor Wayne Cofield, Whitfield Baptist Church, Pastor Paul Forsyth, Gospel Baptist Temple, and Dr Thurman Wade, Executive Director of Macedonia were present.  The following year God allowed us to purchase the house and lot where the Hunter church is now located.

During this time God opened the door for me to preach a lot of different revivals, Bible conferences, camps, and national meetings.  People became interested in our ministry around the country of Peru.  God also opened the door for us to purchase some land for the Bible College.  We had taken the first step towards developing this ministry.

This brought us to the end of our first term and so in December of 1990 we returned to the USA.  After having reported to our churches we returned to Peru in January of 1992

Upon returning to Peru we almost immediately began formal classes of the Peru Bible College.  We had experienced a great deal of setbacks in the ministry as the young preacher boys were not strong in the faith and several had fallen into different sins.  We had to have a time of discipline and correction in order to get the work off the ground again.

Classes started in the Bible college in March and also in March we started the Hunter Baptist Christian School.  In desperation and really scared to death we began the construction of the Hunter church without any money.  We thought we would just build one column at a time and as always God did great things and we were able to finish the first and second floors of the back part of our building.

Octavio Paredes then went out and started a church in Alto Alianza.  God greatly blessed and Brother Aldo Asto donated his house and land to the church.  Shortly after that God opened the door for Aldo to begin working in a church with Mike Fester.  Aldo became the pastor of the church in Ampliacion Paucarpata.  Then Manuel Sanchez, a Mexican missionary, arrived in Arequipa.  He started the church in October the 4th and Miguel Murillo went to work with him.  The Hunter church helped with an offering to purchase their pews and our folks also went to visit and help get the church going.
 
Victor Ocampo also got the opportunity to go to Quillabamba and become the pastor of the Quillabamba
Baptist Church.  The David Bolos family, Word for the World, arrived in Arequipa and began language studies and shortly after the Hayward Duke family arrived to study the language also.  After language school the Bolos started the Pachacutec church with Cesar Copa while the Hayward Duke family started the church in Miquel Grau with Felipe Choquehuanca.

The Bolos family also felt the leadership of God to start the New Hope Baptist Children's Home.  God also touched Jorge Montenegro's heart to give us a house in Mollendo to start a church there with the hopes of  reaching his people.

Really even before this God began touching the heart of Chris Gardner to work as a missionary here in Peru.  Chris took the church in Belaunde and God gave them land and we have completed a first step towards their building.  We were also enabled by God to begin building on the church in Alianza. 

Now after 15 years of ministry in Peru, the team of missionaries has been used by God to start nearly 50 churches, enroll over 100 students in Bible college, establish a deaf ministry, a television ministry, a rescue ministry, a Christian school, a language school, and a children’s home. Many young people travel to Peru every summer on short term mission trips.

God has greatly blessed this ministry.  May it impact and help you as a student in the Baptist College for World Evangelism.

 

  

Application Form

 

Please fill out your answers and mail or email it back to the proper address.

 

Full Name (as appears on your passport):

Address:

Alternate Address:

Phone Number:

Alternate Phone Number:

Email:

Age:

Birthdate:

Gender:

Shirt Size:

 

Parent’s Names:

Parent’s Phone Numbers (if different from above):

If younger than 18, do you have their permission to enroll:

 

Church:

Church Address:

Church Phone Number:

Church Email:

Pastor’s Name:

Pastor’s Phone Number:

Is your pastor willing to recommend you to enroll:

 

Salvation Date:

Brief Account of Your Salvation Testimony:

 

 

 

 

Reason(s) Why You Want To Participate in the BCWE:

 

 

 

 

What dates would you be able to go?  (Please put yes by the one that applies.)

            January – June 2004:                                     June – December 2004:

            January – June 2005:                         June – December 2005:                   

            January – June 2006:                         Other:

 

Do you meet the requirements listed on the “Requirement Sheet”:

 

 

 

 

Pastor’s Recommendation Form

 

Please fill out and mail to: Travis Snode, 209 Bald Cypress Dr., Clover, SC  20710

 

Name:__________________________________________

 

Church:_________________________________________

 

Phone Number:__________________________________

 

 

How long have you known ___________________(student’s name):

 

 

Do you recommend that this person participate in the Baptist College for World Evangelism:___________________________________________________________________

 

If not, please explain why:_______________________________________________________ ____________________________________________________________________________________________________________________________________________________________

 

Other Comments:______________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

Signature__________________________________________

 

Date________________________

 

Covenant

 

My Personal Promise and Covenant for the Baptist College for World Evangelism—Peru, SA

 

I recognize and accept the following conditions which will further the usefulness and safety of my time as a student in the Baptist College for World Evangelism.  I understand that Peru is commonly referred to as a third world country and does not have the same conveniences that I am used to at home.  I realize how important it is to be flexible and willing to adjust to the expectations of my teachers.  If accepted as a member of the BCWE I agree to the following statement:

 

s         I will go as a servant-disciple of Jesus Christ and will adopt that attitude when dealing with fellow students, missionaries, and other people I meet while in Peru.

s         I realize and agree that this is leadership training and not a vacation.  I want enroll in the BCWE to learn more about missions, learn how I can serve God better, and be a blessing to other Christians and the missionaries on the field.

s         I will accept and submit to the leadership role and authority of the missionaries/teachers and promise to abide by his or her decisions as they concern this mission trip.

s         I agree that in the event my conduct is considered so unsatisfactory that it jeopardizes the success of the trip, and that mediation during the trip has failed to correct my behavior, that my services in connection with this mission shall end and I shall return home immediately at my own expense.

s         If a loved one or dear friend is traveling with me, we agree to interact with all members of the team, not just one another.  I promise not to initiate or seek new romantic relationships with other students during my time in Peru. 

s         I understand that I am not permitted to date while I am in Peru.

s         I will avoid any actions, which might be perceived as amorous attentions toward indigenous people I meet.  I will not flirt with or date any Peruvians or national of the countries that we visit.

s         I will always pay my own way!  I will be careful not to allow the missionaries or national pastors to pay my expenses.

s         I will be a blessing to the missionaries I am visiting.  If a missionary accompanies me on an outing or excursion, I will do my best to pay for the missionary’s entry fees and meals.  The missionary is only going as a guide and has probably been there several times already.

s         I will not expect the missionaries to be my maids.  They aren’t offering room service.

s         I will help out!  I won’t sit there and let the missionaries serve me.  I will go to the kitchen; see what I can do to help; pick up after myself, take my dishes to the kitchen, help wash dishes, make up my bed, ask what I can do to help.  I will be a blessing that the missionaries will remember and be glad and thankful that I were there.

s         I will not complain about the food, lodging accommodations, etc.

s         I will be a gracious guest.  If my lodging is in a missionary (or national) home, I will remember I are a houseguest.  This home has been opened to me.  It is not a motel to be treated carelessly because I paid for the room.

s         I will be respectful of the missionary’s home.  Whenever I stay in his home, I will treat the possessions of the owner with care.  I will always leave a home and the furnishings in as good a condition as I found them.  I will not drape wet towels over the back of varnished dining room chairs, leave my beverage glass sitting in a puddle of water on the coffee table or end tables, etc.  I will not go into the closet or kitchen cabinets to get out clothing or food without permission.  Many times the missionary has candy or special foods that he has brought from the states that will be rationed to his children over a long period of time.  I will respect the missionary’s right to privacy.

s         I will conscientiously set aside time to have my personal devotions, to take care of daily responsibilities both spiritually and physically. 

s         I will attend all services, activities, outings, etc. and carry my share of the load in the work we are trying to accomplish.

s         I will maintain and exhibit a good attitude that will honor and glorify the Lord Jesus Christ. 

s         I will not take lightly my important responsibility of setting an example.  I will remember that I the new Christian from another part of the world and will be watched very closely. 

s         I will submit to the instructions concerning attire, eating, drinking and other such traditions, which will help me to assimilate into the local community.  (See Dress Code)

s         I promise not to be overly demanding, to do my best not to offend or cause embarrassment for our missionary hosts, and to help them attain their long-term goals.

s         As a Christian, I realize that it is my responsibility to die to myself and seek to serve others.  I will not seek my own but that of others.  This means not putting myself first and leaving the others out.  I will try to be a blessing to all I meet and especially those that I have come to minister to.

s         I realize that others on my team, during the journey, and while onsite will look at me for an example of how a Christian acts, and I will not treat that responsibility lightly.  I understand that travel, especially to remote locations, can be difficult, and I promise to adopt a flexible attitude and be supportive as plans may need to be changed.  I understand that I must travel with the rest of the team.

s         Before I give a gift to someone I will consult with the teacher and missionary and allow him to make the final decision on this matter.

s         I release and discharge the organizations and individuals which helped me make these agreements, including Baptist College for World Evangelism, Macedonia World Baptist Missions, their agents, employees, officers and volunteers, from all claims, demands, actions, judgments, or executions that I have ever had, or have or claim to have against these organizations, their agents, employees, officers and volunteers, and their successors or assigns for all personal injuries, known or unknown and injuries to property, real or personal, caused by, or arising out of this journey.  I intend to be legally bound by this statement.

 

In signing below, I represent that I am 18 years of age or older, or my parent/guardian will sign also, accepting the above conditions on my behalf.

Participant’s Signature:_____________________________________________________

If participant is under 18 years of age, parent or legal guardian’s signature:

________________________________________________________________________

Participant’s Name:_____________________________________________(please print)

Address:______________________________________________________(please print)

_____________________________________________________________

Daytime phone:_______________________   Evening phone:______________________