EmailMe Form - Application for Short-term Missions

Today's date

MM / DD / YYYY

Trip's preference year

Kenya estimated and flexible dates

Gender

Male

Female

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Cell phone #

### - ### - ####

Work phone #

### - ### - ####

Email

Date of birth

MM / DD / YYYY

Country of Citizenship

Country of birth

Do you have a passport?

Yes

No

If yes, passport number

Date of expiration

MM / DD / YYYY

Name as it appears on passport

First Last

airline ticket purposes

If no, date passport applied for: Date of issue

MM / DD / YYYY

Adult marital status

Please check one

If married, spouse's name

First Last

Is your spouse supportive of you applying for this trip?

If no, please explain

Names and ages of children

My health is

Please state any major illness(es) or surgeries you have had in the last 5 years.

Are you currently under the care of a physician?

If yes, explain

Are you currently taking any medication?

If yes, what?

Please list any allergies you have

Do you have any special health needs?

If yes, explain

Insurance carrier

Policy number

In case of an emergency please notify

First Last

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Cell phone #

### - ### - ####

Work phone #

### - ### - ####

Home phone

### - ### - ####

Secondary emergency contact

First Last

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Cell phone #

### - ### - ####

Work phone #

### - ### - ####

Home phone #

### - ### - ####

Beneficiary to be listed on insurance and relationship

Do you speak any foreign languarges?

If yes, please list them and indicate your level of proficiency

Please indicate any skills, talents, spiritual gifts or Christian ministry experiences that you feel may be helpful on the field

Please list previous missions experience