Mission Trip Application "*" indicates required fields Location of the trip for which you are applying Full Name as it appears on your passport Address Street Address City State / Province / Region Home PhoneCell PhoneEmail Date of Birth MM slash DD slash YYYY Gender Country of Birth Current Nationality Passport Number Passport Exp. Date Place of Issue What is your marital status?SingleMarriedDivorcedWidowWidowerEmergency Contacts2 Contacts - Name, Relationship, Home Phone, Cell PhoneBeneficiaryName & Relationship Health Insurance Company Policy Number Phone NumberCurrent Medications & DosesPrescription & Non-PrescriptionCurrent Medical, Physical, or Other ProblemsSerious Illness or Operations in the Last 12 MonthsImmunizations in the Last Ten YearsDate of Last Tetanus Shot MM slash DD slash YYYY Please list all allergies (food, insect, drugs, plants, etc...)Have you ever had any of the following conditions? Asthma Bronchitis Cancer Sinusitis Dizziness Heart Kidneys Sleep Walking Stomach Diabetes Other Please explain any of the aboveOccupation Special Skills Foreign Language Where are you a church member? Which Life Group/Small Group/Sunday School class? What other ministries do you participate in? Have you ever served as a short-term (2 days - 6 weeks) or a long term (more than 6 weeks) missionary?If yes, please explain.Briefly share your salvation testimonyVarious cultures hold different attitudes toward certain behaviors. Do you agree, for the sake of the Gospel of Jesus Christ worldwide, to follow the guidance of national Christian leaders in matters such as appropriate attire, touching between the sexes, dancing, use of tobacco, etc.?YesNoElectronic SignaturePlease understand that by signing these documents, you will be submitting to a code of conduct that befits a Christian representing Christ and First Baptist Church Haughton. Behavior that is not respectful to the team leader and to authority or to team members will result in termination of your participation of this and future mission trips. Authorization: "I certify the facts contained in this application are true and complete to the best of my knowledge. I also authorize the use of any information in this application to verify my statements. I also release the information in this application to the trip Team Leader(s) and the FBCH Missions Committee." Date MM slash DD slash YYYY Security question:*1+3= CAPTCHA