| Full Name: |
|
| Street Address: |
|
| City: |
|
| State: |
|
| Zip Code |
|
| Country: |
|
| Phone: |
|
| E-Mail Address |
|
| Date of Birth: |
|
| Sex: |
Male
Female |
| Marital Status: |
Single
Married
Divorced |
| Are you a U.S. Citizen? |
Yes
No |
| Parent or Guardian's
name and address: |
|
| Are you a born again Christian? |
Yes
No
|
| If yes,
please explain: |
| How long have you been a Christian? |
|
| Name of Church of which you are a member: |
|
| Pastor's Name: |
|
| How long have you been a member? |
|
|
Highest Level of School Completed: |
| Elementary: |
1
2
3
4
5
6
7
8 |
| High School: |
9
10
11
12 |
| College: |
C1
C2
C3
C4 |
| Other: |
|
| College, University, or Vo-Tech, Seminary, you
have attended: |
|
| Major, if decided: |
|
|
Medical History: (Check any that may apply) |
Allergies
Using Medication
Special Diet |
Asthma
Diabetes
Heart Problems |
Epilepsy
Other
|
| If other, please explain: |
|
| Do you have hospital insurance coverage? |
Yes
No |
| Do you know of any physical, mental or medical
problems that you might have which could hinder you on the
mission field? |
Yes
No |
| If so, please explain: |
|
|
Please provide 3 Christian references of your
choice including a recommendation from your pastor: |
1.
2.
3. |
Phone:
Phone:
Phone:
|
| Have you ever been on a mission trip? |
Yes
No |
| If so, where? |
|
| Have you traveled to a foreign country? |
Yes
No |
| If so, where? |
|
| Do you speak any foreign languages or have you
studied any in school? |
Yes
No |
| If so, which ones? |
|
| Do you play any musical instruments? |
Yes
No |
| If so, which ones? |
|
| Have you ever led a person to the lord in a
salvation experience? |
Yes
No |
| Do you witness or evangelize? |
Yes
No |
| If so, where? |
|
| Do you have any vices (smoking, drinking,
chewing tobacco, ect...)? |
Yes
No |
|
Please write in a short paragraph why you feel
led to go to the mission field: |
|
|
|
What do you expect of a trip like this
and what would you like to accomplish? |
|
|
