Black Voices Intensive Application Remember answers on this browser? Stores your answers incase the browser closes. (Not recommended on public computers) Order Number We recommend writing the longer answers in a separate application and copying & pasting them here so you have back up incase you experience any issues submitting the form. First Name: * Last Name: * Phone Number: * Email Address: * Gender: * I'm a Dude I'm a Lady Age: * Date of Birth * Address: * City: * State: * Zip: * Country: * Emergency Contact Information: First Name: * Last Name: * Phone Number: * Are you currently a university student? * Yes No How did you meet Jesus and give your life to Him? * What do you hope to get out of the Black Voices intensive? * Why is the gospel an important part of the race discussion? * Are you currently on any medication? * Are there any addictions that you are currently working through? * Are there any skill sets that you have that would be helpful for us to know about? * Is there anything further you’d like to let us know? $15 Application Fee - Online Payment: Please enter the card details for the credit/debit card you'd like to use below: First Name: * Last Name: * Credit Card Number: * CVC: * Expiration Date: * Zip: *