Missionary Trip to Costa Rica

Sponsored by SoCal Kids, Southern California District Council of the Assemblies of God

Date:April 23-29, 2016

Cost:$1750-subject to change due to airfare(Includes air travel, lodging, food)

Ministry:Street Evangelism & ministry in churches

Working with Missionary Mary Mahon. Training children’s ministry leaders and pastors.

Maximum Participants: 8

Procedure:

  1. Fill out the application form: Adult (above 18 years of age).
  2. Once you receive confirmation of approval from SoCal Kids, send in a $500 depositto SoCal Kids. Checks should be made out to: So Cal Network.
  3. If you are accepted to participate in the mission’s trip, you must immediately apply for your passport if you do not yet have one.
  4. Payment Due Dates:

January 5: $500.00 (non-refundable deposit)

February 5: $500.00 payment

April 5: Final Balance Due

SoCal Kids Ministries

2016 MISSIONS TRIP TO Costa Rica

APPLICATION FORM - ADULT

(18 or older at time of trip)

Procedure: (All potential applicants, including leaders, must complete an application.)

  1. Accurately complete Parts 1-4 of application, including NotarizedConsent Form.
  2. Attach a headshot photo of yourself.
  3. Once you receive confirmation, send in a check for $500 deposit to the SoCal Kids office. Itmust be received by January 5th, 2016.
  4. Upon acceptance, you will receive more details regarding the trip. At that point you must apply for a passport (if you do not already have one), complete a background check, and start fundraising.

PART 1 – APPLICANT INFORMATION

Please type or print clearly using ink. Use your legal name as it appears on your birth certificate or passport.

First Name ______Middle ______Last Name ______

Phone (_____) ______Birthday ___ - ___ - _____ Age ______Sex ______

Address ______City ______State ____ Zip ______

Country of Citizenship ______Social Security Number: ______

Social Security Number: ______

E-mail Address ______

Parent(s) Name ______Phone (____) ______

Church Name ______City ______Pastor’s Name ______

Do you have a passport? ______From what country? ______Expiration Date: ______

Note: You must have a passport to travel to Costa Rica.

Education Information

What year of schooling have you completed? ______

Do you speak a foreign language? ______Which one? ______How well? ______

Special awards and honors ______

Special skills, abilities, or musical talents ______

Health Information

Are you in excellent health? ______T-Shirt Size ______

Have you ever had any physical handicaps? ______If yes, explain ______

Height ______Weight ______Will you be willing to eat whatever food you are served? ______

If not, please explain your diet requirements______

Are you bringing any medication on this trip? _____ If yes, please list: ______

Are you allergic to any medications? _____ If yes, please list: ______

PART 2 – SPIRITUAL EXPERIENCE

Please give a brief account of the following:

  1. Your spiritual experience. Include information concerning your salvation story, water and Holy Spirit baptism. Relate how, when, and where for each.
  2. Your experience in Christian ministry: Include what you have done, when, where and with whom you have worked.
  3. Relate your reasons for wanting to participate in this MissionsTrip.
  1. Your spiritual experience (salvation story, water and Holy Spirit baptism, etc.) ______
  2. Your experience in Christian ministry (involvement at church, prior mission’s trips, leadership at school, etc.) ______
  3. Reasons for wanting to participate in this missions trip ______

PART 3 – ADULT CONSENT FORM

MISSIONS TRIP TO Costa Rica 2016 ASSUMPTION OF RISK (ADULT)

All team members 18 years of age & older at the time of the trip must complete this form

And have it NOTARIZED as part of their application.

I (name) ______, in consideration of my acceptance as a member of the SoCal Kids Ministries 2016 Missions Trip Outreach to Colombia in cooperation with the Southern California Network of the Assemblies of God represent and agree that:

  1. I am a volunteer and acknowledge that I am not an employee of the General Council of the Assemblies of God or any District Council of the Assemblies of God.
  2. I am aware of the hazards and risks to my person and property associated with serving in a mission’s capacity, such hazards and risks including, but not being limited to, death or injury by accident, disease, terrorist acts, weather conditions, inadequate medical services and supplies, criminal activity, and random acts of violence. I accept my assignment with full awareness of these risks, and I voluntarily assume all risk of death, injury, illness, and damage to myself or any members of my family associated with such risks. I further recognize that such risks have always been associated with missionary service. 2 Corinthians 11:23-28.
  3. I attest and certify that I have no medical conditions that would prevent me from performing my duties.
  4. I waive any and all claims for damages which I, or my heirs or successors, may have against the General Council of the Assemblies of God or any District Council of the Assemblies of God arising from my death, injury, or illness, or any property damage or loss occurring during the term of my assignment or as a result of my assignment.
  5. In the event that I have minor children who will accompany me on my assignment, I, acting both on my behalf and in their behalf as their parent and legal guardian, do hereby assume all risks of death, illness, or injury that they may suffer as a result of said assignment, from those causes described above.
  6. I expressly waive any defense to the enforcement of any provision of this commitment arising from a claim of lack of consideration and warrant that this commitment constitutes a legal, valid, and binding obligation upon me, enforceable against me in accordance with its terms.
  7. I understand and accept the following policy of the Assemblies of God World Missions regarding ransom payments:

The Foreign Missions Board has determined that it will not pay ransom nor yield to the demands of anyone who takes hostage one of our staff of volunteer’s hostage. The Assemblies of God World Missions pledges itself to every effort in prayer and all other appropriate means to obtain the release of one taken hostage should it ever occur. This po9licy was made after sufficient study of the policies of other evangelical missionary societies and after considering the advice of the United States State Department.

  1. I expressly agree that this assumption of risk and indemnity agreement is intended to be as broad and inclusive as permitted by law. I further state that I HAVE CAREFULLY READ THE FOREGOING ASSUMPTION OF RISK AND UNDERSTAND THE CONTENTS THEREOF, AND I VOLUNTARILY SIGN THIS RELEASE AS MY OWN FREE ACT.

Signature ______Date ______

For 18yr old and older

CONFIDENTIAL

Date: ______Male______Female

Name: ______Birthdate: ______

Social Security Number: ______- ______- ______Telephone: ( _____ ) ______

Address______City______Zip______

Church: ______City: ______

Senior Pastor: ______Tele: (_____) ______

Have you ever been convicted of, or pled guilty or no contest to a crime other than a minor traffic violation, or are you now under charges for any criminal offense? A criminal conviction will not necessarily disqualify you from consideration.

Yes______(If yes, please list the question number and explain fully on an additional sheet)

No______.

As a Missions Team Member, I will dedicate myself to the spiritual welfare of the other members of my team. I will follow the policies set up by the staff and/or director. I will cooperate fully with the leaders of the team and do my best to represent Christ in everything that I do.

Read Carefully before Signing

  • The information contained in this application is correct to the best of my knowledge.
  • I authorize the church listed above to release any information they may have regarding my character and fitness to participate in the mission’s trip/ including all information gained from a criminal records check from any and all agencies. I hereby release any individual, church, denominational agency or official, reference, or any other person or organization, including record custodians, both collectively and individually, and whether or not identified in this application, from any and all liability for damages of whatever kind or nature which may at any time result to me, my heirs, or family, on account of compliance or any attempts to comply with this authorization, excepting only the communication of knowingly false information. I further state that I HAVE CAREFULLY READ THE FOREGOING OWN FREE ACT. This is a legally binding release which I have read and understand. I understand that I may consult with an attorney before signing this document. A facsimile or photocopy of this authorization shall be as valid as the original. I further understand that a criminal records check may be conducted on me and I consent to any such check…

I have read and understand the above provisions, and agree to them.

______

SignatureDate

PART 4 – PASTOR’S REFERENCE

Applicant’s Name ______

Dear Pastor:

We would appreciate your confidential comments on the applicant’s maturity, stability, temperament, ability to adjust to new situations, physical stamina and any other traits or qualities which might be assets or liabilities. Exposure to pressures, cultural shocks and physical stress places a great demand on the character and disposition of each applicant. Because we do not know the applicant personally, we must rely on your recommendation. Please complete the form and return it to us as soon as possible. The candidate’s application cannot be processed until your evaluation is received. Please feel free to make any additional comments on a separate sheet and attach to this form. Thanks for your help.

  1. How long have you been acquainted with the applicant? ______In what relationship? ______
  2. Do you believe the applicant to be an outstanding member of your church? ______
  3. Would you recommend him/her, without reservation, to this mission’s trip? ______
  4. State briefly your opinion of his/her dedication to Christ. ______
  5. What leadership abilities has he/she evidenced? ______

______

  1. What special talents has he/she shown? ______

______

7. Are his/her Christian standards above reproach? ______

8. To your knowledge, is he/she in good health? ______

9. Does he/she have any emotional, mental, or physical handicaps? ______

Please check the following:ExcellentGoodFairPoor

Spiritual depth and maturity    

Ability to get along with others    

Follows through on instructions    

Cooperation    

Teachability    

General attitude    

Disposition    

General Appearance    

Faithfulness to church    

Faithfulness to youth activities    

In my estimation, the applicant would be:  Excellent  Good  Fair  Poor for the missions trip because ______.

Signed ______Date ______

Church ______Phone (___) ______

Address ______City ______State _____ Zip ______

Return these forms to: SoCal Kids Ministries Department, 17951 Cowan, and Irvine, CA 92614

All Missions Trip applications from your church are due by January 5th, 2016

With a $500.00 deposit per person. Please make your check to: SoCal Network

Because the Missions Team consists of both minors and adults, a background check is required for all adult team members. If the person listed below has previously completed a background check through your church, all that is required is that you, as pastor certify it. Great reliance is placed on the representation of each applicant’s pastor to insure the applicant’s suitability for working with minors. If a background check has NOT been done, leave this form blank and it will be done by Hispanic Ministries.

PLEASE CLEARLY PRINT THE FOLLOWING INFORMATION

I am personally acquainted with ______for 77approximately ______.

(Name) (6-month minimum)

He/she is competent and qualified to work with minors of any age.

I know of no facts or allegations that raise any questions concerning his or her suitability for working with minors in any activity. We have run a criminal background check on the applicant and find no reason that he/she would not be suitable for working with minors in any activity.

The date the criminal background check was completed ______

The company used was ______

The applicant’s history was:

______clear______showed criminal background

*If criminal background was shown please provide an explanation.

______

______

______

______

______

Senior Pastor’s Name (Please Print)Church & City

______

Senior Pastor’s SignatureDate

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