Domestic Mission Application
Email address *
Name *
Your answer
Date of Birth
MM
/
DD
/
YYYY
Trip Destination *
Trip Departure Date
MM
/
DD
/
YYYY
Are you a member of CLBC?
Do you attend a Bible Fellowship Class?
Medical & Emergency Contact Information
Emergency Contact Name and Relation
Your answer
Emergency Contact Number
Your answer
Emergency Contact Email
Your answer
Complete Insurance Information or Send a picture of your insurance card front and back.
Send to Donna@crosslanesbaptist.org, please continue with application.
Insurance Company
Your answer
Policy #
Your answer
Group #
Your answer
How is your health?
Are you prone to motion sickness?
List any major illnesses, operations or serious injuries (including dates) in the past 5 years.
Your answer
List all medications you are currently taking, indicating which medications you will be taking while on the trip.
Your answer
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.
Your answer
Travel Insurance Beneficiary Name and Relation *
Your answer
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 representatives of liability in case of injury, loss, damage or accident that you might encounter while on this short-term mission trip? (If under 18 Your parent(s) must enter his or her name(s) below.)
Please enter your name as your signature to the consent for medical treatment and the release of liability.
Signature of Applicant
Your answer
Signature of Parent if Applicant is under the age of 18.
Your answer
Do you consent to us keeping your information on a secure external drive for subsequent trips?
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service