EmailMe Form - YA Mexico Outreach Application

Part One: General Information
Today's Date *
MM / DD / YYYY
Select Mexico Team you are joining: *
Full Name *
First Middle Last
Preferred Name *
First Last
Date of Birth *
MM / DD / YYYY
Gender *
Male
Female
Age *
Marital Status *
Single
Married
Divorced
Seperated
Widowed
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Email *
Cell Phone *
### - ### - ####
Home Phone
### - ### - ####
Part Two: Passport Information
Do you currently have a valid passport? *
Yes
No
If yes, please upload a color copy of your passport *
If no, please answer the following:
Have you applied for a passport?
Yes
No
If yes, please upload a copy of your receipt of payment
Do you have other documentation (i.e. Green Card, etc.)
Yes
No
If yes, what type of documentation do you have?
Name as on Document
Issuing Country
Document Number
Expiration Date
Part Three: Spiritual Information
Please list your spiritual gifts, skills, training, etc. *
What ministries and/or church activities are you currently involved? *
Which WOL Global Outreach Trips have you been on in the past? *
Have you been on outreach/mission trips in the past outside of WOL? *
Yes
No
If yes, where did you go, when, with what organization and what was the purpose of the trip?
Part Four: Mexico-Specific Information
Do you speak Spanish? *
Yes
No
Are you able to lead worship? *
Yes
No
If yes, what giftings do you have?
Would you be able to drive your own vehicle? *
Yes
No
If yes, how many people, other than yourself, does your vehicle hold?
*if you drive you will need to provide proof of a valid driver's license and insurance*
Part Five: Health & Personal Information
This will be kept confidential and viewed only by Outreach Staff and your Team Leader(s)
Have you ever been hospitalized for a physical or emotional condition? *
Yes
No
If yes, please explain:
Are you currently receiving counseling? *
Yes
No
If yes, please explain:
Please list any allergies, dietary needs, illnesses or chronic conditions. *
Are you currently taking any anti-depressant medications? *
Yes
No
If yes, please explain:
Please list ALL medications you are taking and for what condition:
Medication Name
Condition Being Treated
Have you ever been arrested? *
Yes
No
If yes, please explain:
Part Six: Emergency Contact Information
First Contact
Name *
First Last
Relationship to Applicant: *
Cell Phone *
### - ### - ####
Day Time Phone *
### - ### - ####
Evening Time Phone *
### - ### - ####
Second Contact
Name *
First Last
Relationship to Applicant: *
Cell Phone *
### - ### - ####
Day Time Phone *
### - ### - ####
Evening Time Phone *
### - ### - ####
Part Seven: Short-Term Mission Trip Risk Acknowledgement and Release
Trip Information:

Sponsoring organization (Trip Sponsor): Water of Life Community Church

Nature of mission trip: Evangelism, teaching, ministry support

Name of trip sponsor's coordinator: Dominique Santiago

Phone: 909.463.0103 x4148 Email: Dominiques@wateroflifecc.org

Location of Mission Trip: *
Trip Start Date: *
MM / DD / YYYY
Trip End Date: *
MM / DD / YYYY
Participant Information*

Name of Participant: *
*to be completed by the participant or by parents/guardians if participant is a minor
Age (if under 18):
Birthdate (if under 18):
MM / DD / YYYY
Name of parent(s)/guardian(s) (if applicable):
Cell phone/contact number:
### - ### - ####
Is sponsor authorized to approve medical treatment? *
Yes
No
Is participant covered by personal/family medical insurance? *
Yes
No
If yes, name of insurer: *
Policy or Group Number:
I acknowledge that participation in the above trip involves risk to the Participant (and to Participant's parents or guardians, if Participant is a minor), and may result in various types of injury including, but not limited to the following: sickness, exposure to infectious/communicable disease, bodily injury, death, emotional injury, personal injury, property damage and financial damage. In consideration for the opportunity to participate in the above trip, the Participant (or parent/guardian if Participant is a minor) acknowledges and accepts the risks of injury associated with participation in the trip. The Participant (or parent/guardian) accepts personal financial responsibility for any injury or other loss sustained during the trip, as well as for any medical treatment rendered to the Participant that is authorized by the Sponsor (Water of Life Community Church) or it's agents, employees, volunteers, or any other representatives (collectively referred to hereinafter as the "Trip Sponsor"). Further, the Participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the Trip Sponsor for any injury related directly or indirectly out of the above trip, whether such injury arises out of the negligence of the Trip Sponsor or otherwise.

I authorize the Trip Sponsor to consent to any x-ray, examination, anesthetic, medical or surgical diagnosis or treatment on the advice of any physician or surgeon licensed to practice in the state of treatment, on behalf of the Participant (or parent/guardian) when the need for such treatment is immediate, and when efforts to contact parent/guardian are unsuccessful. I understand that the Trip Sponsor is not responsible for costs incurred for medical care.

If a dispute over this agreement or any claim for damages arises, the Participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the Participant (or parent/guardian) and the Trip Sponsor cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution pursuant to the rules of the American Arbitration Association.
Part Eight: Outreach Covenant
Each trip participant is required to read and sign this covenant. Check each box below to indicate your agreement with the following statements:
I will complete a binding release of liability.
I will yield to the authority of the Global Outreach Department and the appointed Leader(s) of the outreach trip.
I will take all questions and concerns to my Team Leader(s) first.
I will not consume tobacco products or alcoholic beverages throughout the duration of the outreach.
I will be culturally sensitive to the rules and behaviors between men and women in-country.
I will not enter into a romantic relationship with a teammate throughout the duration of the outreach.
If you are currently in a romantic relationship with a teammate you will not show inappropriate public displays of affection. The Team Leader may discuss this further with you if he or she deems it necessary.
I will have a quiet time each day.
I will never go anywhere alone without permission from a Team Leader.
I will not go anywhere with a member of the opposite gender without permission from a Team Leader.
I will NOT go outside my leaders to establish relationships, contact our partners or give financial donations without communicating and discussing it with my Team Leader(s) and/or the Global Outreach Department at WOL.
I will be mindful of excessive use of technology including cameras, phones, social media, etc.
I have carefully read the above Covenant. I agree to all statements and will follow them in-country. *
Yes
Printed Name of Participant *
*Printed name of participant or parent/legal guardian if participant is a minor