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

Are you a born again Christian?

Yes   No

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 like this and what would you like to accomplish?