LINDSAY LANE BAPTIST CHURCH

MISSION PROJECT PARTICIPANT

APPLICATION

A. PERSONAL INFORMATION

Name: Click here to enter text. ☐ Male ☐ Female Date: Click here to enter a date.

Present Address Click here to enter text.

City: Click here to enter text. State: Click here to enter text. Zip Code: Click here to enter text.

Marital Status: ☐Single ☐Married ☐Widowed

TELEPHONE NUMBERS
Home: Click here to enter text. Work: Click here to enter text.Cell: Click here to enter text.

Email: Click here to enter text.

Date of Birth: Click here to enter text. Social Security Number: Click here to enter text.

Citizenship: Click here to enter text. Country of Birth: Click here to enter text.

PASSPORT INFORMATION

Passport Number: Click here to enter text. Expiration Date: Click here to enter text.

City and State Where Issued: Click here to enter text.

Name as It Appears on Passport: Click here to enter text.

EMERGENCY CONTACT

Name: Click here to enter text. Relationship to You: Click here to enter text.

Address: Click here to enter text.

City: Click here to enter text. State: Click here to enter text. Zip Code: Click here to enter text.

Telephone Numbers
Home: Click here to enter text. Work: Click here to enter text. Cell: Click here to enter text.

B. MISSION PROJECT DESCRIPTION

Name of Mission Project: Click here to enter text.

Team Leader: Click here to enter text.

Dates of the Project: Click here to enter text. Field Assignment (Country): Click here to enter text.

Please describe the ministry you will have on the field. (What is the purpose of the trip?):

Click here to enter text.

C. CHURCH INVOLVEMENT

Church Membership: ☐Lindsay Lane ☐Other Church Click here to enter text.

How long have you been a member? Click here to enter text.

Have you accepted Jesus Christ as your personal Savior and Lord? ☐Yes ☐No

When did this happen? Click here to enter text.

List the ministries you have served with in your church or outside your church, including time of involvement &

any leadership positions held: Click here to enter text.

Have you had training in evangelism? ☐Yes ☐No

Would you like some refresher training in evangelism before this mission trip? ☒Yes ☐No

Please indicate any foreign language training, special skills, talents, or Christian service experience that you feel

may be helpful on the field: Click here to enter text.

Please list past mission project experience (Country - Mission - Organization - Dates – Ministry):

Click here to enter text.

D. REFERENCES

PROVIDE TWO REFERENCES. One reference should be a church pastor or department director in a ministry

in which you serve. The other reference should be someone who knows your ministry abilities as well as your

strengths and weaknesses.

(1) Name: Click here to enter text. Relationship: Click here to enter text.

Address: Click here to enter text.

City: Click here to enter text. State: Click here to enter text. Zip Code: Click here to enter text.

Telephone Numbers: Home: Click here to enter text. Work: Click here to enter text.

(2) Name: Click here to enter text. Relationship: Click here to enter text.

Address: Click here to enter text.

City: Click here to enter text. State: Click here to enter text. Zip Code: Click here to enter text.

Telephone Numbers: Home: Click here to enter text. Work: Click here to enter text.

E. MEDICAL INFORMATION (To be completed by participant or an authorized guardian)

Is parent/guardian (in Section F below) authorized to approve medical treatment? ☐Yes ☐No
Is participant covered by personal/family medical insurance? ☐Yes ☐No

If yes, name the insurer: Click here to enter text.

Policy or group number: Click here to enter text.

How would you describe your present health? ☐Excellent ☐Good ☐Average ☐Poor

Please state any major illness(es) you have had in the last five years: Click here to enter text.

Are you presently under the care of a physician? ☐Yes ☐No If yes, please explain: Click here to enter text.

Please list any medication you are taking: Click here to enter text.

Please list any allergies you have: Click here to enter text.
Please explain any physical challenges that you may face on this mission trip: Click here to enter text.

MISSION PROJECT DESCRIPTION

Name of Mission Project: Click here to enter text.

Team Leader: Click here to enter text.

Dates of the Project: Click here to enter text. Field (Country): Click here to enter text.

F. PARTICIPANT or PARENT (GUARDIAN) PERMISSION (As Applicable)

PARTICIPANTS OVER 18 YEARS OF AGE

By signing below, I agree to comply with all requirements stated in the Lindsay Lane Baptist Church

Mission Project Manual, which I have read and understand. I also authorize Lindsay Lane Baptist Church or its representatives to initiate any medically necessary care on my behalf in the event of my incapability to present myself for such care, and agree to be financially responsible to any care provider. I authorize the release of any necessary medical or insurance related information pertinent to the circumstances. I hereby release Lindsay Lane Baptist Church from any liability of injury or medical conditions encountered during this mission trip.

__________________________________/__________________________________ _____________________

Participant Name (Print) Participant Signature	Date

PARTICIPANTS UNDER 18 YEARS OF AGE

MUST BE ACCOMPANIED BY AT LEAST ONE PARENT OR GUARDIAN.(Team Leader/Parents review any special legal requirements that may exist for this minor to travel to/from this destination - consult Manual & Missions Staff)

By signing below, I (the participant) agree to comply with all requirements stated in the Lindsay Lane Baptist Church Mission Project Manual, which I have read and understand.

__________________________________/__________________________________ _____________________

Participant Name (Print)	Participant Signature	Date

By signing below, we the parents/guardians give our son/daughter permission to participate, and at least one of us will accompany our son/daughter at all times. In the above stated mission project with Lindsay Lane Baptist Church and its representatives. We hereby release Lindsay Lane Baptist Church from any liability of injury or medical conditions encountered during this mission trip. We also authorize Lindsay Lane Baptist Church or its representatives to initiate any medically necessary care on our son/daughter’s behalf in the event of our son/daughter’s incapability to represent them self for such care, and agree to be financially responsible to any care provider. We authorize the release of any necessary medical or insurance related information pertinent to the circumstances. If required, I willing carry the original birth certificate for our son/daughter.

__________________________________/__________________________________ _____________________

Parent/Guardian Name #1 (Print) Parent/Guardian Signature	Date

__________________________________/__________________________________ _____________________

Parent/Guardian Name #2 (Print) Parent/Guardian Signature	Date

NOTARY PUBLIC SECTION

State of ______________________ County of _____________________________

day of ________________, 20____.

____________________________________	PLACE SEAL HERE

Notary Public

My Commission Expires: ____/_____/20____

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Team Leader: Does Applicant (If applicable):

____ Have a current passport?	____ Have appropriate shots/vaccinations?

____ Have a clear background check within 3 years? ____ Have appropriate Travel Insurance?

____ If a minor, have an accompanying parent/guardian

Team Member Approved for this Mission Project	____ If a minor, have necessary documents?

_______________________________ _________________________/_______________

Team Leader Name (Print) Signature	Date

PROVIDE ORIGINAL TO THE MISSIONS STAFF, Provide a copy to the participant – KEEP A COPY IN CUSTODY DURING TRIP