Application

Please Choose Our-Trip-Dates on your Right (pt/et-optional)

PT= PRE-TEAM *

Oct 17-20 / 2017 Mar 13-16 / 2018 Oct 10-12 / 2018

TT= TEAM TRIP *

Oct 21-28 / 2017 Mar 17-24 / 2018 Oct 13-20 / 2018

ET= EXTENDED TOUR *

Oct 28-Nov 4 / 2017 March 24-31 / 2018 Oct 19-26 / 2018

Phone Number *

Emergency Contact *

Cell Number *

Emergency Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

High-School Name *

High-School City *

Graduate High-School? *

Yes / GED No Attending

State *

Graduate College? *

Yes No Attending

College Name -1 *

College City *

State *

College Name -2 *

College City *

State *

List Certificates / Degrees / Awards *

Employer Name *

Employer Email *

Phone Number *

Phone *

Occupation *

Skills/Training *

Hobbies/Interests *

Pastor Email *

Pastor Number *

Your Church Position *

Member Deacon Elder

* *

Secretary Sunday Tchr Youth Pastor

* *

Ass. Pastor Pastor Other

If Other Position - List Below *

For How Long Have You Attended? *

Briefly Share Your Conversion To Jesus *

Physical Stats *

Excellent Average Poor

Mental Stats *

Excellent Average Poor

Mental Illness History? *

Yes No

Physically Disabled In Any Way? *

Diagnosed With Mental Disorder? *

Name And Purpose Of Medications - If Any *

Name of Medications/Foods You Are Allergic To? *

Are You A Vegetarian? *

Yes No

Other Foods You Abstain From? *

Yes No

List Type of Vegetarian & Other Foods You Abstain From *

Please List Tobacco Products You Smoke/Chew? *

History Of Drug Use? *

Yes No

History of Alcohol Abuse? *

Yes No

Name/Address of Drug/Alcohol Rehab Facility? *

Ever Been To or Currently Participate in AA, NA os SAA? *

Please Tell Us Anything Else You Think We Need To Know *