Young Church-Service Missionary Recommendation Form

Attach photo here. Dress in proper missionary attire.

Once the Young Church-Service Missionary Recommendation Form has been completed, including the signatures of the applicant and parent or guardian on page 3, the prospective young Church-service missionary should meet with his or her bishop for a worthiness interview and to discuss his or her specific abilities and limitations. When the bishop has approved the application, the prospective young Church-service missionary (YCSM) meets with the stake president for a worthiness interview. The stake president should work with the local Church-service missionary group coordinators to determine a mission specific to the YCSM so that it fits the applicant’s skills and abilities. The Church-service missionary group coordinators process the YCSM’s mission call.For those who live in Utah, this form should be submitted by the stake president to the young Church-service missionary coordinators in the Church Office Building, who will work with the stake president to find appropriate service opportunities for the YCSM. This form can be faxed to 1-801-240-1726 or scanned and emailed to ycsm@ldschurch.org. For further clarification or assistance, please call 1-801-240-4914.Important: Please enter or clearly print all information.Applicant InformationName (first, middle, last) Birth date (month, day, and year) Home phone (with area code) Cell phone (with area code)

Mailing address City State or province Postal code

Email address Membership record number Gender

□ Male □ FemaleName of person to notify in case of emergency Relation to applicant Home phone (with area code) Cell phone (with area code)

Desired length of service (check one)□ 24 months  □ 18 months  □ 12 months  □ 6 months

Today’s date Availability date

Do you hold a current driver’s license?□ Yes  □ No

Do you have a vehicle available for transportation?□ Yes  □ No

Are you able to use public transportation?□ Yes  □ No

Do you have a trained service animal for assistance?□ Yes  □ No

Have you ever been arrested?□ Yes  □ No

If yes, explain charge and resolution Date of arrest (if applicable)

Have you ever been convicted of a crime?□ Yes  □ No

If yes, explain charge and resolution Date of conviction (if applicable)

Health InformationGeneral health□ Good  □ Fair  □ Poor

Eyesight□ Good  □ Fair  □ Poor

Hearing□ Good  □ Fair  □ Poor

Name of medical insurance provider Policy number

Medical Conditions1. Do you have or have you ever had any of the following:

a. Back injury or back problems . . . . . . . . . . . . . . .□ Yes  □ No b. Heart disease or heart trouble . . . . . . . . . . . . . .□ Yes  □ Noc. Seizures, convulsions, or paralysis . . . . . . . . . . .□ Yes  □ No

d. Dizziness or fainting spells . . . . . . . . . . . . . . . . .□ Yes  □ No

e. Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .□ Yes  □ Nof. Physical limitations . . . . . . . . . . . . . . . . . . . . . . .□ Yes  □ No

g. Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .□ Yes  □ No

2. Are you currently taking medication of any type?□ Yes  □ No

3. Do you have or have you ever had any other physical or medical impairments or disabilities, including mental or emotional disorders?□ Yes  □ No

4. Have you visited a doctor in the last five years?□ Yes  □ No

If yes, doctor’s name Phone (with area code)

If the answer is “Yes” to any of the questions above, give the details of each (attach additional pages if necessary)

© 2012, 2013 by Intellectual Reserve, Inc. All rights reserved. Printed in the USA. 9/13. PD50051661

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Education and SkillsEducation□ High school□ Post-high school transition□ Vocational training□ College

Degree(s) received English reading level□ Low□ Medium□ High

English speaking level□ Low□ Medium□ High

List or describe your computer experience (word processing, spreadsheets or databases, presentation software, and so on)

List or describe your oral and written communication skills, other language proficiency, office skills, interpersonal skills, hobbies, and current vocational interests

Employment History List employers and positions held (attach additional pages if necessary). If ever employed by the Church, include employee ID number.Employer name Position held and employee ID number (if applicable)

Employer name Position held and employee ID number (if applicable)

Church InformationPresent Church calling(s) Previous Church positions held

Have you served a mission before?□ Yes □ No

If yes, dates of missionFrom   to 

Name of mission (if applicable)

Additional missions served (if applicable)

Honorably excused from full-time proselyting service by:□ Priesthood leader If so, name and position □ Missionary DepartmentSpecial ConsiderationsDescribe any special considerations, need for supervision, self-care needs, or concerns in other areas such as interpersonal skills

Describe transportation arrangements (indicate if you are near to and can take public transportation or if family members are able to provide transportation)

Other CommentsProvide any other helpful information such as needs for family support, medical problems, and so forth

Suggested AssignmentsList any suggestions or desired service opportunities for potential young Church-service missionary assignments

Young Church-Service Missionary Recommendation Form—continuedName (first, middle, last)

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Name (first, middle, last)

Agreement and Signatures

I understand that, if called, I will not be a Church employee and that I will not be eligible for and will not receive monetary compensation or other employment benefits in connection with my service. I understand that I will be freely volunteering my time during my mission experience.Medical Privacy NoticeAs part of my Recommendation Form, I have voluntarily provided my personal health information. I provide this information to help the Church determine an appropriate mission assignment and Development Plan and to make those I work with as I serve as a missionary for The Church of Jesus Christ of Latter-day Saints aware of my health situation and my abilities and limitations. I agree that the Church may use my health information to develop activities related to my Development Plan. I agree that it further may be used to educate and communicate with job counselors and other professionals and organizations that may be involved in creating, facilitating, monitoring, and assessing my Development Plan. I understand the Church will maintain the privacy of my health and other personal information in accordance with Church policy. Except as provided above, the Church will not use or disclose my heath information without my additional authorization, except as required by law or when the health or safety of myself or of others is jeopardized as determined in the Church’s reasonable discretion. I authorize the Church and its affiliated entities to share my health information for the purposes noted above. I agree that the following can receive my health information:1. Representatives and employees of the YCSM division ofThe Church of Jesus Christ of Latter-day Saints.2. My assigned mission leaders, facilitating couples,mission assistants, and assigned job or related counselors.3. My home unit priesthood leaders (such as the bishop and stake president) and counselors and clerks who may assist my local priesthood leaders (such as ward and stake clerks).4. Representatives and employees of other charitableorganizations where I am assigned to labor as part of mymissionary service.This authorization is valid from the date of execution until one year after I am released from my mission, unless revoked in writing before that time. I certify that the health information I have provided is true and complete.

Insurance and Medical ExpenseI understand that the Church does not provide any insurance or pay for any medical expenses for young Church-service missionaries. I have been encouraged to maintain any existing family medical insurance or other existing coverage during my mission. If medical issues arise for which I do not have coverage, I have been encouraged to address those concerns with my bishop as part of his responsibility to oversee Church welfare. I understand that I am required to provide my own medical insurance coverage during my mission service.Data Privacy AuthorizationI hereby authorize The Church of Jesus Christ of Latter-day Saints, its officers, employees, affiliated entities, and departments—including my mission leaders and my home unit priesthood leaders, such as the bishop and stake president, and counselors and clerks who may assist my local priesthood leaders—to process my personal and sensitive data for purposes relating to missionary service in the Church. I have informed my parents and/or caregivers that I will include some of their personal data in my missionary recommendation as my emergency contacts. I understand that my bishop or branch president and my stake president or district president will provide evaluations of my qualifications to serve as a missionary. I agree that these evaluations are related to determining my worthiness and capacity to serve as a missionary. I understand that these evaluations are strictly confidential, and I hereby waive any right of access to these evaluations.I hereby authorize the Church service missionary office or local Church-service missionary group coordinators, development counselors, and priesthood leaders to share the above medical information with the management of the department(s) where I will serve.I understand that my bishop or branch president and my stake or mission president will provide evaluations of my qualifications to serve as a young Church-service missionary. I understand that these evaluations are strictly confidential, and I hereby waive any right of access to these evaluations.

Signature of prospective missionary Date

Signature of parent or guardian Date

Young Church-Service Missionary Recommendation Form—continued

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Mission AssignmentName of department or organization Name of supervisor Supervisor phone number Supervisor email address

Length of service (check one)□ 24 months  □ 18 months  □ 12 months  □ 6 months  □ Other

Schedule

Start date Monday Tuesday Wednesday Thursday Friday Total hours per weekDepartment or organization name

Department or organization name

Department or organization name

Bishop’s or Branch President’s Recommendation and Signature By signing this form, you are certifying that the applicant is worthy to hold a temple recommend and is capable and qualified to serve as a young Church-service missionary.Name of bishop or branch president Complete ward or branch name Unit number

Mailing address City State or province Postal code

Home phone (with area code) Work phone (with area code) Cell phone (with area code) Email address

Comments

Signature of bishop or branch president Date Candidate’s membership record is annotated

□ No □ YesStake or Mission President’s Recommendation and Signature By signing this form, you are certifying that the applicant is worthy to hold a temple recommend and is capable and qualified to serve as a young Church-service missionary.Name of stake or mission president Complete stake or mission name Unit number

Mailing address City State or province Postal code

Home phone (with area code) Work phone (with area code) Cell phone (with area code) Email address

Comments

Signature of stake or mission president Date Candidate’s membership record is annotated

□ No □ Yes

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Young Church-Service Missionary Recommendation Form—continued