Country Trip Dates
General Information
Full Name
Mailing Address City
State Zip Code
Email Address
Phone (Home) Phone (Work)
Phone (Cell)
Gender: Male Female
Marital Status: Single Married Spouse's Name
Experience and Gifts
Previous Mission Experience
Language Proficiency: Fluent Just a little None Language(s)
Special skills, gifts, and abilities you bring to the team:
In a few words, describe your relationship with God:
Why do you want to go on this mission trip?
What do you hope to gain from your trip experience?
Have you talked to the specific trip leader about your interest?
Yes No
Emergency Information
Emergency Contact (Please do not list people traveling with you on this trip.)
Name Relationship
Phone (Cell) Email Address
Insurance/Health Information
Every participant involved in a Christ Community sponsored trip is required to have major health insurance while in-country (Christ Community arranges this, and the cost is included in the price of your trip). While this insurance is primarily medical, it does include some life insurance. Therefore, please list the following:
Beneficiary Name Relationship
Do you have any health problems that might be an issue if you travel and work in another cultural setting?No Yes (Please explain)
Passport Information
Passport Number Citizenship
Date of Issue Date of Expiration
Date of Birth Place of Birth
(Please mail two copies of your valid passport to Michelle Bieri; Christ Community Church; 1301 15th St.; Greeley, CO; 80631 or email them to michelleb@cccgreeley.org.)
Endorsement
The following ministry leader has recommended me to represent Jesus Christ and Christ Community Church on this cross-cultural mission trip.
Name of Ministry Leader