EmailMe Form - Samaria Mission Short Term Application

Samaria Mission Short Term Application
Over the years Samaria Mission has had a number of volunteers serving during our outreach time. The time span for these short-termers is anything from 1 month to 1 year. If you have any trouble submitting this application please email smshorttermer@gmail.com

Name you go by *

First

Last

Date of Birth *

YYYY

Name as it Appears on your Passport *

Passport Number *

Passport Expiration Date *

YYYY

Address *

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

Primary Phone Number *

###

####

Secondary Phone Number

###

####

Personal Email *

First Emergency Contact Person *

First

Last

Relationship *

Primary Phone Number *

###

####

Secondary Phone Number

###

####

Email *

Second Emergency Contact Person *

First

Last

Relationship *

Primary Phone Number *

###

####

Secondary Phone Number

###

####

Email *

Local Church Name *

Pastor's Name *

First

Last

Church Phone Number *

###

####

Church Email *

Years Attending *

Home Church Name
(if different from local church)

Pastor's Name

First

Last

Church Phone Number

###

####

Church Email

Years Attending

References: Please provide 3 references
You must also provide a reference letter from each reference
(See instructions on www.samairamission.net - short-termers)

First Reference (MUST be your Pastor) *

First

Last

Years Known *

Pastor's Phone Number *

###

####

Pastor's Email *

Second Reference (MUST be your Youth Pastor or a church leader) *

First

Last

Relationship *

Years Known *

Phone Number *

###

####

Email *

Third Reference (May be an employer or personal friend) *

First

Last

Relationship *

Years Known *

Phone Number *

###

####

Email *

Miscellaneous Information

Dates you are available to serve with Samaria Mission *

List any mission trips that you have been a part of in the past (place and year)

Any Known Allergies

Any Known Food Allergies

Any Known Medical Conditions

Medical Insurance Company Name *

Medical Insurance Company Phone Number *

###

####

Medical Insurance Plan Number *

Medical Insurance Expiration Date *

YYYY

Describe how and when you became a Christian AND your current walk with the Lord: *

What is your current involvement in your local or home church? *

Why do you want to serve as a short-termer with Samaria Mission? *

What do you want to accomplish while serving with Samaria Mission? *

How might your skills, talents, training or gifts be useful while serving with Samaria Mission? *

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