West Side Christian Church

Mission Trip Application

PERSONAL DATA (please print clearly or type)

Full Name ______

Last, First Middle

Address ______

Street City, State Zip

Email Address ______Home Phone ______

Cell Phone ______Work Phone ______

Date of Birth ______

Marital Status (circle) Single Married Divorced Widowed

Spouse’s Name ______

EMERGENCY CONTACT INFO

Name #1 ______

First Last

Address ______

Street City, State Zip

Email Address ______Home Phone ______

Cell Phone ______Work Phone ______

Name #2 ______First Last

Address ______

Street City, State Zip

Email Address ______Home Phone ______

Cell Phone ______Work Phone ______

EXPERIENCE

Skills, Talents, Foreign Languages & Ministry Experience

Please list any skills, interests, hobbies or talents: (teaching Bible school lessons, crafts, puppets, building, agricultural or mechanical skills, medical training, sewing, sports, etc.) Describe your ability and experience for each item you list:

______

Missions Experience

Have you ever been on a mission trip before? If so, where? Describe your experience. ______

______

Why do you want to go on this specific mission trip? (New York) ______

______

What will make you a valuable asset to this missions team? ______

______

References(optional)

Please provide the name and info of 2 references who know you well and who are not related to you:

Name ______Relationship ______

Home Phone ______Cell Phone ______Email ______

Name ______Relationship ______

Home Phone ______Cell Phone ______Email ______

PERSONALITY PROFILE

How do you think OTHERS view your personality? ______

______

Describe your personal strengths. ______ ______

Describe your personal weaknesses. ______

PERSONAL RELATIONSHIP WITH JESUS

Have you been baptized by immersion? ______Yes ______No

When did you become a Christian? ______

Describe your conversion experience ______

______

Describe your personal relationship with Jesus ______

______

RELEASE FORM

  • I understand that I am expected to abide by all West Side Christian Church Missions rules while on this trip. This includes, but is not limited to, refraining from use of alcohol, cigarettes or other drugs while on the trip, following all directions put forth by trip leaders and maintaining moral integrity and a respectful attitude at all times.
  • I also release and hereby agree to hold blameless West Side Christian Church and its employees and agents from any and every claim arising, or which may be asserted by me or by any member of my family for reason of participating in the activities associated with this mission trip.
  • I do authorize trip leaders the authorization to give consent to a physician and/or hospital for emergency medical treatment while on this trip. It is understood that I will assume any financial responsibility for any expense that may be incurred for emergency treatment or for transportation home, if necessary.
  • West Side Christian Church will not be responsible for personal injury or loss of valuables of any kind.

I have read, understand and will abide by all policies set forth by West Side Christian Church. I also understand that noncompliance may result in immediate dismissal from the trip at my own expense.

______

Signature Name (print) Date

Insurance Information

Health Insurance Company ______

Policy Number ______

Primary Doctor/Physician ______

Location of Physician ______

Medical Facility City State

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