Contact Email Address

Mission Trip Location

Trip Dates

Participants Legal Name

Participants Nickname

Participants Gender * Participants Gender *MaleFemale

Home Phone

Cell Phone

Parent / Guardian Name if Minor

Parent/Guardian Phone

Parent/Guardian Email

Students Email

Parent/Guardian Place of Employment

Parent/Guardian Business Phone

Address

Parent/Guardian Address if Different

Grade (if applicable)

Marital Status * Marital Status *SingleMarriedSeperatedDivorcedEngagedWidowed

Spouse Name

Spouse Phone

Is your spouse supportive of your participation?

Passport First Name

Passport Middle Name

Passport Last Name

Passport Suffix

Passport Number

Passport Expiration Date

Passport: Date of Birth

Passport: Citizenship

Passport: Country of Birth

May we keep your passport info on file?

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone

Is sponsor authorized to approve medical treatment? * Is sponsor authorized to approve medical treatment? * YES No

Is participant covered by personal/family medical insurance? * Is participant covered by personal/family medical insurance? * YES NO

If Insured: Name of Insurer

Policy or Group Number (Also, please drop a photocopy of the card off at the church office)

Travel Insurance Beneficiary Legal Name

Travel Insurance Relationship

Describe Present Health * Describe Present Health *ExcellentGoodAveragePoor

Please state any major illness(es) you have had in the last five years:

Please list any medications you are taking:

List Any Allergies You Have

Please explain any physical challenges you may face on this trip:

Are You a Member of a Church? * Are You a Member of a Church? * YES NO

If Yes, Name of Church

If Yes, How Long Have You Been a Member?

Are you an Active Regular Member of a Small Group * Are you an Active Regular Member of a Small Group * YES NO

If Yes, Name of Teacher

Have You Been on a Short-Term Missions Project Before? * Have You Been on a Short-Term Missions Project Before? * YES NO

If Yes, When & Where

Have You Had Training in Personal Evangelism? * Have You Had Training in Personal Evangelism? * YES NO

Describe your life before a personal relationship with Jesus. How and when did you come to know Jesus as Savior?

How is your life now that you know Him? Describe your relationship with Jesus.

Have you seen spiritual growth over the last year? If so, please describe the growth.

Briefly describe why you see God calling you to participate in this mission trip.

What talents/spiritual gifts do you have that would be used on the mission trip? What do you see your role as?