International Mission Application
Short term mission team application
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Email *
Name as it appears on Passport (or as it will appear if not yet received) *
Date of Birth *
MM
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DD
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YYYY
Trip Destination *
Trip Departure Date *
MM
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DD
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YYYY
Do you have a passport *
If no, have you applied for a passport? *
If yes: passport number
Issue Date
MM
/
DD
/
YYYY
Expiration Date
MM
/
DD
/
YYYY
Are you a member of CLBC? *
Do you attend a Bible Fellowship Class? *
Medical & Emergency Contact Information
Emergency Contact Name
Emergency Contact Number
Emergency Contact Email
Emergency Contact Relation
Complete Insurance Information or Send a picture of your insurance card front and back.
Send to Donna@crosslanesbaptist.org, please continue with the application.
Insurance Company
Policy #
Group #
How is your health? *
Are you prone to motion sickness?
Clear selection
List any major illnesses, operations or serious injuries (including dates) in the past five years.
List all medications you are currently taking indicating which medications you will be taking while on the trip.
List any dietary restrictions and/or any food allergies and the side effect if these foods are consumed along with medication to counteract any adverse reactions.
Travel Insurance Beneficiary Name *
Beneficiary Relation to you *
Do you consent to the Team Leader making medical decisions on your behalf (or on behalf of your child) in the case of an emergency? *
Do you understand the risks associated with traveling to this particular destination and do you release Cross Lanes Baptist Church and its representitives of liability incase of injury, loss, damage or accident that you might encounter while on this short-term mission trip? *
Do you understand the risks associated with traveling to this particular destination and do you release Cross Lanes Baptist Church and its representitives of liability incase of injury, loss, damage or accident that you might encounter while on this short-term mission trip?
If you are under the age of 18 at least one parent is required to enter his or her name as well.
Do you agree with the previous question?
Clear selection
Enter your name as your signature. *
If you are under 18 your parent(s) must enter his or her name(s) below as his/her signature(s).
Do you consent to us keeping your information on a secure external drive for subsequent trips? *
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