Docstoc

Mission Trip Application

Document Sample
Mission Trip Application Powered By Docstoc
					Mission Trip Application
July 17 – 25, 2010
A $70 deposit is required in addition to this application.


                         Student Information

Full Name:

Address:

Home Phone:                                           Cell Phone:

Email (one that you use!)

School:                                           Grade:


           Parent/Guardian Contact Information
                              (skip if over 18 yrs)


Parent or Guardian’s Name:

Address:

Home Phone:                                  Cell Phone:

Alternate Phone:

Email Address:

Non-Parent Emergency Contact Name:

Home Phone:                                  Cell Phone:

Alternate Phone:




              Pastor Jerry Luengen, Youth Pastor
 1525 SW Dash Point Rd * Federal Way, WA 98023 * 253-839-6085
General Questions
What is your relationship with God?



Please describe any event or experience you consider to be milestones in your spiritual
growth or relationship with Christ.


In what area(s) is God currently working in your life?



Why do you want to participate in the 2010 mission trip to Montana?



What would make this upcoming mission trip a success for you?



During this trip, there may be opportunity for personal evangelism. Are you comfortable
sharing your faith with others? If you have never done so, are you open to learning how
and practicing?




Costs
The approximate total cost of the event is $600. This fee may be lower depending upon
the amount of kids attending. We will refund or adjust this number as we come closer to
the event. The following is an outline of payment due dates:

 February 17th: Application and $70 Deposit: This fee is refundable before April 1.

 March 14th: $50 Due. Non-refundable

 June 13th: $300 Due. Non-refundable

 July 2nd: $180 Due. Non-refundable
Applicant’s Mission Trip Agreement
  I pledge to . . .

           Respectfully obey all rules, accept the authority of the leaders, and behave in
            a manner consistent with a follower of Jesus Christ.

           Keep a positive, cheerful attitude and remember the goal of this trip is to serve
            and minister to others. I will serve when, and in the way, asked of me without
            complaining or delay. This will include prayer, worship, manual labor and
            working with children.

           Uplift my fellow trip members – never putting them down, experience
            fellowship and Christ-like community with them, avoid the appearance of evil,
            never walk anywhere alone (unless asked to in an emergency).

           Follow the Path Youth Ministries Trip Guidelines document.

           Begin preparing for the event personally, by praying and reading God’s Word.

           Attend all Path Youth services unless personally excused by youth leadership
            staff. This includes Sunday School, Wednesday night service and the church
            worship service.

           Attend all mission trip training sessions unless otherwise excused by youth
            leadership staff.

           Participate in all group fundraising activities unless otherwise excused by youth
            leadership staff. I understand that if the entirety of funds are not raised I will
            have to cover the difference with personal funds.




Signature                                         Printed Name                                   Date
Medical Information
NOTE: This form must be filled out in order for you to participate in the Mission Trip to Montana. The information on
this form will be used to seek medical attention while on the trip if the need should arise. This information may be
seen by members of the Youth Leadership Team, Mission Trip chaperones, and qualified medical personnel. Every
effort will be made to keep this information confidential.



               Parent/Guardian Permission, Release, and
                    Consent for Medical Treatment
                                      (even if you will accompany your child)

As the parent or legal guardian of _________________________________________, I give permission for
him/her to participate in the Federal Way Church of the Nazarene Youth Mission Trip to Blackfeet Nation,
Montana from July 17 – 25, 2010.

I agree to assume all financial responsibility resulting from my child’s behavior or actions requiring
additional expenses; including but not limited to damages to the property of others and any and all
additional costs should it become necessary to send my child home early including an airplane ticket if
necessary. I understand this will also include the cost of a chaperone’s expenses to return your child AND
the cost of returning the chaperone to the mission site so that the chaperone can continue the mission trip.

It is understood, should medical care be required, our family’s insurance is to be the primary insurance
coverage.

I hereby release the Federal Way Church of the Nazarene, its staff and sponsors, from responsibility and
liability for any injury or illness that my child may sustain during this event. I hereby authorize an adult
leader of this event, as agent for me, to consent to an X-ray examination; medical, dental or surgical
diagnosis; treatment; dispensing of medication including non-prescription medication, and hospital care
advised and supervised by a physician, surgeon, nurse or dentist (as appropriate) licensed to practice in the
United States. In the event of an emergency, I expect to be contacted as soon as possible. I have read this
release, I understand that it waives certain rights and I am signing it voluntarily.

Allergies including food allergies:



Medications being taken include as needed and over the counter items (allergy, inhaler, bee sting items)




Medical conditions or physical handicaps:



Other information we should know including injuries or surgeries that might be relevant to mission service
while in Montana. (Please remember the youth will be performing emotional, physical, and spiritual labors
on this trip.)
Physician                                                         Physicians Phone #

Medical Insurance Company

Member’s Name

Group #                                                   Group Name

Policy #


Consent to Treatment
In an emergency, I give my permission to a licensed physician to hospitalize or anesthetize me, or perform
surgery on me. I understand that every effort will be made to inform my emergency contact before these
actions are taken.




Signature of Parent                                    Printed Name                                  Date
or Legal Guardian
      Adult Medical Information and Treatment Release

I, ____________________________________________________, intend to participate in a mission trip with
the Federal Way Church of the Nazarene to Blackfeet Nation, Montana from July 17 – 24, 2010.

I agree to assume all financial responsibility resulting from my behavior or actions requiring additional
expenses; including but not limited to damages to the property of others.

It is understood, should medical care be required, our family’s insurance is to be the primary insurance
coverage.

I hereby release the Federal Way Church of the Nazarene, its staff and sponsors, from responsibility and
liability for any injury or illness that I may sustain during this event. In the event that I am rendered
unconscious (and my spouse is not available) I hereby authorize an adult leader of this activity, as agent
for me, to consent to any X0ray examination; medical, or surgical diagnosis; treatment; and hospital care
advised and supervised by a physician, surgeon, or nurse (as appropriate) licensed to practice either in the
United States or in the country where services are rendered. In the event of an emergency, I expect my
family to be contacted as soon as possible. I have read this release, I understand that it waives certain
rights and I am signing it voluntarily.


Allergies including food allergies:


Medications being taken include as needed and over the counter items (allergy, inhaler, bee sting items)


Medical conditions or physical handicaps:


Other information we should know including injuries or surgeries that might be relevant to mission service
while in Montana. (Please remember the youth will be performing emotional, physical, and spiritual labors
on this trip.)

Physician                                                          Physicians Phone #

Medical Insurance Company

Member’s Name

Group #                                                    Group Name

Policy #
Consent to Treatment
In an emergency, I give my permission to a licensed physician to hospitalize or anesthetize me, or perform
surgery on me. I understand that every effort will be made to inform my emergency contact before these
actions are taken.




Signature                                              Printed Name                                  Date

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:1
posted:2/1/2013
language:English
pages:7