Government Information

Name:

First Name

Last Name

D.O.B:

YYYY

God Given Biological Sex:

Email:

Phone:

(###)

###

####

Emergency Contact Information #1

Emergency Contact Name #1:

First Name

Last Name

Emergency Contact Phone Number #1:

(###)

###

####

Emergency Contact Information #2

Emergency Contact Name #2:

First Name

Last Name

Emergency Contact Phone Number #2:

(###)

###

####

Personal/Skillful Information

Any Need To Be Disclosed Medical Conditions:

Write N/A if none.

Any Allergies:

Write N/A if none.

Commitment

Can you commit to the entire duration of the missions trip? If not, please explain.

Would you consider yourself flexible?

When on mission things are always changing.

Yes

I acknowledge the cost is $425.00(not including one meal or personal expenses) and if the fundraiser does not cover my expenses that I will be held liable.

Yes

Signature

I hereby declare that all the information provided in this application is true and accurate to the best of my knowledge. I understand the commitment required for this missions trip and agree to abide by the guidelines set by the organizing team.

By typing my name I am signaling this is my signature and this is a fully signed and authorized document.

Signature (First, Middle, Last)

Date Signed:

YYYY

Missions Trip Application