Please Print

Name_____________________________Nickname____________SSN___________ ___

Street Address______________________________________________________ _______

City________________________________________State______ ZIP________________

Male________ Female________ (Augusta is a male prison. Only male team members have direct regular contact with the residents on the weekend. Both men and women are invited to be on the "cook Team" which serves the weekend from a location just outside the prison. The cook team joins the rest of the team , the resident pilgrims and others (men and women) of the Kairos community at the Sunday closing celebration.)

Home phone (___)________ Business phone (____)__________ Date of Birth ____________

Name & Denomination of Church you attend ______________________________________

Location of your church: City______________________________________ State ________

Your church activities/responsibilities: ___________________________________________________________

Where and when did you make your Cursillo/Emmaus (etc.) Weekend? _________________________________

Are you a member of an active share and prayer group? ______________________________

Previous team service [not required] [list teams by number, when, where, jobs held, talks given]________________________________________________________________________________________________________________ __________________________________________________________________________________________ _________________

Do you play a musical instrument?________________ What kind ______________________

 Would you like to play the instrument as part of the music ministry on the weekend? ___________

Before you sign below, please prayerfully consider and agree to the following:

 * I understand, that by serving on a Kairos team, I am obligated, for a period of one year, to attend monthly Gatherings with the Augusta residents who have made the Kairos Weekend.

 * I will read and follow the Kairos Manual that will be offered to me upon my acceptance to serve on a Kairos team. I will make every effort to attend all team meetings held in preparation for this ministry.

* I understand that this application will be checked by the Virginia Department of Criminal Justice for outstanding warrants in Virginia and the US

Signature ___________________________________________ Date: _________________

Please send the completed application to the Vinton, VA address above. Contact Butch Miller by letter, phone, or email to discuss any issues or questions you may have about this event and ministry.