Country Trip Dates
GENERAL INFORMATION
Full Name (as it appears on your passport*)
Mailing Address
City State Zip Code
Email Address Phone (home)
Phone (work) Phone (cell)
Gender: Male Female
Age:
Marital Status: Single Married, spouse's name:
Departure City (if not Denver)
*Please note that your passport MUST be valid for at least six months after your scheduled date of return.
EXPERIENCE AND GIFTS
Previous mission experience:
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 are you hoping to gain from your trip experience?
Foreign languages spoken:
Have you talked to the specific trip leader about your interest?Yes No
MEDICAL INFORMATION
Do you have any known allergies? No Yes (please explain) Do you have any dietary restrictions? No Yes (please explain) Do you have any physical restrictions? No Yes (please explain) Are you currently taking any medications? No Yes (please explain)
EMERGENCY CONTACTS
(Please do not list people traveling with you.)
Name Relationship to you Mailing Address City State Zip Code Email Address Phone (home) Phone (work) Phone (cell)
INSURANCE 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 Relationship to you
ENDORSEMENT
Please list the name of a pastoral reference (or ministry leader) who would recommend you to represent Jesus Christ and our church in a cross-cultural setting.
Reference Name Phone Email Address
ASSUMPTION OF RISK
"By submitting this application, I understand that any mission trip includes an inherent level of risks and dangers, including but not limited to illness, injury, acts of terrorism, death, robbery, kidnapping, or other loss or destruction of life or property. Furthermore, I have reviewed the information about the mission trip country found on the Consular Sheets produced by the U.S. State Department at the following website: http://travel.state.gov/travel/cis_pa_tw/cis/cis_1765.html. I hereby agree to accept any and all risks of injury or death that may result from my participation in this mission trip.
"I also understand that the completion and submission of this application does not necessarily guarantee me a place on the respective mission trip."