The Well Network - Apply For A Trip


MISSIONS APPLICATION
Choose which trip you are applying for: HAITI Mar.11-16 (TX Spring Break) HAITI Mar.19-24 (FL Spring Break) HAITI Apr.1-6 (CA Spring Break) HAITI May 2012 HAITI July 2012 HAITI September 2012 TBD HAITI December 2012 TBD OTHER TEAM TRIP
T-shirt Size (adult unisex)
PERSONAL INFORMATION
Name
Sex
Marital Status
Street Address
City/State/Zip
Home Phone
Cell Phone
Email Address
Do you utilize facebook?
How did you hear about this trip?
What church do you attend?
Name of SENIOR pastor
Place of Employment or School
Job Title or Grade
PASSPORT INFORMATION
Passport Number
Passport Expiration
Name EXACTLY as it appears on passport
Passport Place of Issue
BIRTHDAY
MEDICAL INFORMATION
Did you receive recommended childhood immunizations? YES NO
Please list any additional vaccinations or immunizations received.
Do you have any allergies or medical conditions that could affect your trip? Please explain and list any necessary medications you will be bringing with you.
Health Insurance Company
Policy Number
Name of Policy Holder
Health Insurance Phone Number
EMERGENCY CONTACT
Name of Contact
Relationship
Phone Number (required)
Email Address of Contact
REFERENCES
PASTORAL REFERENCE (Include Name, Church, Email & Phone)
PERSONAL REFERENCE (Include name, relationship, email & phone)
QUESTIONNAIRE
1. Have you ever been convicted of a crime? Yes or no. If yes, please explain.
2. Why do you want to participate in a trip like this?
3. Please briefly describe how and when you became a Christian.
4. Have you been on a mission trip before? When? Describe the trip.
5. What is your greatest fear about going on a trip like this?
6. What is your greatest hope?
7. What gifts and talents can you offer the team?
I have EXPERIENCE or would be interested in the following area(s): CHILDREN'S MINISTRY CONSTRUCTION PROJECTS CRAFTS DRAMA OR SKITS EVANGELISM FOOD DISTRIBUTION MEDICAL CLINIC PRAYER LEADER SPORTS CLINIC WORSHIP
8. Please describe your experience or interest in any areas marked above.
Today's Date