Word Baptist Church - Mission Trip Form

General Information

Name as it appears on your passport.

First Name

Last Name

Gender

Birthdate

Email

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Marital Status

Do you have any children living at home?

Yes

No

Are you a member of Word Baptist Church?

Yes

No

If you are a member of another church, please indicate the name of the church you are a member of:

What Life Group do you attend?

Do you have a current passport?

Yes

No

Passport number:

Does your passport expire during this trip?

Yes

No

Mission Trip Information

Name of Mission Trip

Dates of Mission Trip

Location of Mission Trip

Personal Reference

First Name

Last Name

Email

Have you previously filled out a Word Baptist Church Mission Application in the past 12 months?

Yes

No

Emergency Information

Emergency Contact

First Name

Last Name

Relationship

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Work Phone Number

Email

Health Insurance Provider

ID Number

Group Number

Policy Holder

First Name

Last Name

Employer

Beneficiary

Relationship to you

Health description:

Blood Type

Are you currently taking medication?

Yes

No

If yes, please list all medications you are currently taking:

Do you have any allergies (i.e. animals, plant, food, medicine)?:

Yes

No

If you answered 'Yes", please list all allergies:

Please list your current innoculations and date received (i.e. Hepatitus A/B, Yellow Fever, Tetanus, Typhoid):

Have you been under the care of a physician, counselor, or mental health professional in the last 12 months?

Yes

No

If yes, please briefly explain.:

Spiritual Information

Write out in your own words how a person can become saved:

Write out your salvation story, including when you were baptized:

How are you currently growing in your relationship with Christ (emphasizing your prayer life and Bible study/quiet time)?:

Give a brief explanation of how you know God wants you to be on this project:

Other Information

Excluding minor traffic violations, have you ever been convicted of any violation of any law or ordinance?

Yes

No

Do you have any physical impairment that prevents you from physical work?

Yes

No

Are you living a lifestyle of a pre-marital, extra-marital or homosexual relationship?

Yes

No

Do you completely abstain from the use of alcohol, illegal drugs and tobacco products?

Yes

No

Do you have a daily prayer and Bible study time?

Yes

No

Are you willing to be involved in the visitation outreach of Word Baptist Church before this mission project?:

Yes

No

Today's Date

Mission trip signup

General Information

Mission Trip Information

Emergency Information

Spiritual Information

Other Information