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									                巴拿馬宣道會差會 Christian & Missionary Alliance of Panama
                          PLEASE THIS FORM TO: Kim Pham Chen englishcamp.pa@gmail.com
                                        Questions, call Nick at 403-800-0445

               Short-term Mission Trip for English Ministry Application Form

1. Mission Trip: _________________________ From: ___________ To: ___________ Flight: _______________
2. Name: (English)__________________________ (Chinese)_________________________ Sex : ____________
3. Address: __________________________________________________________________________________
4. Tel.: (Home) ______________________ (Work): ______________________ (Cell) : ____________________
   Fax : _____________________ E-mail : ______________________________ Nationality : _______________
5. Occupation : ________________________________________ Date of Birth : __________________________
6. Languages you speak : □ English □ Cantonese □ Mandarin □ Others _________________________
7. Marital Status :      □Single         □Married        □Divorced      □Separated       □Remarried
8. Emergency Contact: (Name) ____________________________ Tel.: (Home) __________________________
   (Work) _______________________ (Cell) ________________________ Relation: ______________________
9. Have you had any health problem in the past one year?                □No              □Yes
   Please explain: _____________________________________________________________________________
10. Why do you want to join this Short-Term Mission? ________________________________________________
   __________________________________________________________________________________________
11. What do you expect from this Short Term Mission? _______________________________________________
   __________________________________________________________________________________________
12. Are you member of a church?          □Yes          Pastor name: _____________________________________
   Church: __________________________________________________________________________________
   □No Please explain : _______________________________________________________________________
13. Describe your devotional habits: _______________________________________________________________
   __________________________________________________________________________________________
14. List your ministry experiences and position in church: _____________________________________________
   __________________________________________________________________________________________
15. Please provide two references of pastor and church leader:
   Name: ___________________________Tel: ___________________________ Date: _____________________
   Signature: _________________________________Position in church: ________________________________
   Name: ___________________________Tel: ___________________________ Date: _____________________
   Signature: _________________________________Position in church: ________________________________
16. I __________________ will abide to the regulations and policies of the organization during the short-term
    mission trip and be responsible for all the agreed costs.
   Applicant’s Signature: _______________________________________ Date: __________________________

								
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