EmailMe Form - Global Outreach Returner Application

Part One: General Information

Today's Date *

MM / DD / YYYY

Country of Outreach *

Month of Outreach *

Full Name *

First Middle Last

Preferred Name

First Last

Date of Birth *

MM / DD / YYYY

Age *

Gender *

Male

Female

Address *

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

Email *

Cell Phone *

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

Home Phone *

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

Occupation: *

Since: *

Do you speak any other language besides English? *

Yes

No

If so, what languages?

Marital Status: *

Spouse's Name:

Do you have your spouse's support and/or consent?

Yes

No

Spouse's Signature

Clear

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?

If yes, please upload a color copy of your documentation.

Part Three: Team Member Information

Please share why you are applying to be a part of this Outreach Team: *

Please list your spiritual gifts, skills, training, etc. *

Are you able to lead worship? *

Yes

No

If yes, what giftings do you have?

Do you plan to participate in Team fundraising? *

Yes

No

Which WOL Global Outreach Teams have you been on in the past? *

What ministries and/or church activities are you currently involved? *

Part Four: Health & Personal Information

This will be kept confidential and viewed only by Outreach Staff and your Team Leader(s)

How would you rate your present state of health?

Physical *

Emotional *

please explain: *

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. *

If separated or divorced, please briefly share when and under what circumstances.

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

Do you have any physical limitations? *

Yes

No

If yes, please explain:

Have you ever been arrested? *

Yes

No

If yes, please explain:

How do you plan to finance this outreach trip? *

Please explain any financial obligations that may hinder you from going on this trip (including debt, outstanding bills, etc.) *

Part Five: Short-Term Mission Trip Background Check, 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: Lili Arias

Phone: 909.463.0103 x4182 Email: globaloutreach@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

Cell phone/contact number: *

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

Address: *

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

Name of parent(s)/guardian(s) (if applicable):

Cell phone/contact number:

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

Name of emergency contact: *

Cell phone/contact number: *

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

Relationship to participant: *

List allergies, illnesses, physical conditions, medications or anything else WOL should be aware of: *

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: *

Signature:

I acknowledge that there will be a background check performed on the participant and agree to pay the current fee of $13 for this to be completed.

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, 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. *

Clear

Signature of Participant (or parent/guardian if participant is a minor) required above

Today's Date: *

MM / DD / YYYY