Application for Short-term Missions

Name ______Date of Birth______

(As it appears on Passport)

Mission Trip applied for: ______Project #______Passport#______

Address______

Sponsoring Group ______Phone #______

Personal Email______Phone #______

  1. Are you an active member of good standing of Cookeville First Baptist church and attend on a regular basis?______
  1. Do you participate in visitation and outreach at the church? ______

Please share about one of your recent witnessing/outreach opportunity.

______

  1. General Health Conditions:  Excellent  Good  Fair  Poor

List any medical (mental or physical) and/or legal conditions that we need to be aware of that require special care or restrict your daily activities. List chronic diseases, known drug allergies and prescription drug medications you currently take. Attach a separate sheet if necessary.

______

Name of Insurance ______# ______

Does your current Insurance provide coverage outside USA? ______

Emergency Contact ______

______Blood Type ______

Application Release: I understand and agree that FBC and any of its employees, staff, coordinators or members assume no responsibility of loss of property, damage to the same, personal harm, illness or loss of life that may occur during the execution of this volunteer mission project, and I, for myself, my heirs, executor, administrators, distributes, and assigns, in consideration of my admission to volunteer service and other good and valuable considerations, do hereby absolve said FBC and its employees, staff, coordinators or members and hold them harmless from any claim or demand which I or they might conceivable assert upon the basis of the foregoing.

I understand that foreign travel involves health and safety risk and it is my sole responsibility to gather information I need in order to assess the risk involved in any travel, stay or any other activity related to this project. I further understand that I am expected to act in a Christ like manner and cooperate with the coordinator of the trip. I agree to abstain from the use of tobacco products, alcoholic beverages, illegal drugs or any other behavior that would hinder Christian ministry.

Signature______Date ______

Name of Hotel or Point of Contact at destination: ______

Phone: ______Email:______

Please share your salvation experience and your call to go on this trip: ______List Spiritual Gifts and Talents: ______

Complete this section if you are applying for funds.

Date of Trip:______Cost of Trip: ______Amount Applied For ______

Make check Payable to: ______

Are you receiving additional funds? ______(if yes) How much? ______

Have you received scholarship money from FBC in the past 18 months? ______

Date: ______Amt: ______Date; ______Amt: ______

Date: ______Amt: ______Date; ______Amt: ______

  1. Does this trip concur with the Great Commission by providing evangelism and/or discipleship as its primary focus? ______
  2. Fully explain how evangelism will be done or what will be taught: ______

______

______

______

  1. How many times do you expect to share your faith each day? ______
  2. Do you tithe to FBC? ______

CHILD CARE AUTHORIZATION

I(We), the undersigned, ______, parent(s) of ______, hereby grant ______, of Cookeville, Tennessee, the authority to take temporary care of the following child:

This grant of temporary authority shall begin on ______, and shall remain effective through ______.

The above name Caretaker(s) shall have the power to:

-seek appropriate medical treatment or attention on behalf of the child(ren) as may be required by the circumstances, including but not limited to, medical doctor and/or hospital visits.

-Authorize medical treatment or medical procedures in an emergency situation

-Enter and exit the county of ______

Dated: ______

______

Printed Name Printed Name

______

Signature Signature

Notary Public

On this the ______day of ______, ______, personally appeared before me ______, personally known by me and in the presence executed the within and foregoing Child Care Authorization form. Witness my hand and official seal this ______day of ______, ______. My Commission expires ______.