Step 1 of 3 33% Legal name*Trip you are applying forFirst missions trip choice*Mexico (HIM), June 24th - 30th, 2019Mexico (Rancho de Sus Niños), July 1st - 3rd, 2019Botswana/South Africa, July 5th - 19th, 2019Hometown Revival San Marcos, August 13th - 17th, 2019Israel, September 17th - 27th, 2019Nepal, October 21st - November 1st, 2019Second missions trip choice*Mexico (HIM), June 24th - 30th, 2019Mexico (Rancho de Sus Niños), July 1st - 3rd, 2019Botswana/South Africa, July 5th - 19th, 2019Hometown Revival San Marcos, August 13th - 17th, 2019Israel, September 17th - 27th, 2019Nepal, October 21st - November 1st, 2019Do you have a passport?*YesNoPassport NumberDate of passport expiration Must have 6 month validity from post trip date.Country of citizenship on passportUnited StatesAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweAddress*CityState*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZipcode*Home phoneCellphoneEmail OccupationAgeDate of Birth Marital StatusSingleMarriedDivorcedWidowedLanguages spoken (other than English)Are you born again?YesNoIf so, for how longName of pastoral referenceYour reference can be from: a pastor, department, or ministry leader.PhoneHow long have you known them? Christian LifeWhen and how did you become a Christian?*Describe briefly why you want to go.*Tell us about your ongoing relationship with God; what does it consist of from day-to-day.*What gifts or talents do you have that would be beneficial to this trip?Have you been involved in missions work before?Please describe any past missions experience(s).Missions work requires working closely with others. Honestly rate yourself as a team player.*12345678910(1) Poor ––––– (10) ExcellentMinistry ExperienceHave you ever shared your faith with someone else?*YesNoIf yes, how many times?List your involvement or service in ministryI am willing to be used by God in the following areas (check all that apply) Repair/Construction Evangelistic street ministry Visitation ministry (Homes, hospitals, orphanages, etc) Medical ministry Teaching/Training Prayer ministry Children/Youth ministry Music/Worship ministry Drama/Dance Background HistoryHave you been involved with illegal drugs in the past year?*NoYesDo you have a record of criminal offense in any country*NoYesDo you currently use tobacco or alcohol of any sort?*NoYesPlease provide additional information on background history.Medical InformationHow would you describe your present health?ExcellentGoodAveragePoorAre you able to walk 3-4 miles a day comfortably in hot weather?*NoYesDo you have any physical disabilities or conditions, which prevent you from performing certain types of activities such as hiking, lifting, riding in vehicles for long periods of time, and carrying up to 50lbs, 8-10 consecutive hours of continuous work?NoYesPlease describe any physical conditions/disabilitiesAre you currently under any medical supervision and/or have you had any life-threatening diseases or symptoms of such disease in the past 12 monthsNoYesPlease describe any medical supervision or life-threatening issues you've had in the past 12 months.Have you ever had or experienced any of these medical conditions. Diabetes Seizures Fainting spells Eating disorder Respiratory problems Psychiatric care Addiction problems Physical/Sexual abuse Heat exhaustion Please list any other known medical conditions (heart problems, etc) or physical disabilities that might make this trip difficultDo you have any allergic reactions to any type of: medicines, bee stings, food, etcNoYesPlease describe any known allergiesAre you taking any medication at this time?*NoYesDo you have any special dietary needs due to a health condition?NoYesDo you foresee any problems with the nature of this trip and/or climate concerning your health and/or physical condition?NoYesEmergency ContactIn case of emergency, we will notify the person you list.Emergency contact nameRelationshipPhoneMedical insurance companyAuthorization #Policy and group #Physician's namePhoneConsent for Talent and Use of ImageTalent and Use Consent* I agree.I give permission for Summit Church to use my image and likeness in the form of photos, videos, and personal testimony, for promotion of church and missions projects in the church, television, or internet.Date* Consent for Medical TreatmentMedical Treatment Consent* I agree.I understand the risk involved in the trip I will be a part of. By checking the consent agreement, I indicate that knowledge and in case of emergency, I hereby agree to the performance of such treatment, including: anesthesia and surgery, as the standing physician may deem necessary and release Summit Church, it's officers, and partners of any liability in any case of my injury or death.Date CommentsThis field is for validation purposes and should be left unchanged.