Domestic Mission Application
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Email *
Name *
Date of Birth
MM
/
DD
/
YYYY
Trip Destination *
Trip Departure Date
MM
/
DD
/
YYYY
Are you a member of CLBC?
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Do you attend a Bible Fellowship Class?
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Medical & Emergency Contact Information
Emergency Contact Name and Relation
Emergency Contact Number
Emergency Contact Email
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
Policy #
Group #
How is your health?
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Are you prone to motion sickness?
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List any major illnesses, operations or serious injuries (including dates) in the past 5 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 and Relation *
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?
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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
Signature of Parent if Applicant is under the age of 18.
Do you consent to us keeping your information on a secure external drive for subsequent trips?
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Submit
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