SBCV Rebuild Haiti Trip Registration Form
Thanks for your willingness serve the people of Haiti. We ask God to help you to continue to grow in grace and in the knowledge of our Lord and Savior Jesus Christ. I pray that God will prepare and use us to encourage and challenge each other as we glorify God by serving the people of Haiti. Please fill out the attached form then HIT the SUBMIT at the bottom of the form to register for the trip and secure your Mission Trip Emergency Medical Insurance.
Contact Information
Name
Your answer
Email
Your answer
Cell Phone
Your answer
Home Phone
Your answer
Work Phone
Your answer
Home Address
Street Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Dates you are available to serve in Haiti
I am available to serve in Haiti
Please register me to serve on the following team(s)
Passport Information
Official Name - As it Appears on Passport
Your answer
Date of Birth
Your answer
Passport Number
Your answer
Passport Expiration Date
Your answer
Church Information
Church's Name
Your answer
Church Address
Your answer
Membership Status
If you are not a member, please select other and explain your relationship to the church.
Pastor's Name
Your answer
Pastor's Email
Your answer
Emergency Medical Insurance Information
SBC of Virginia will provide Emergency Medical Insurance
Name of Beneficiary
Your answer
Beneficiary's Telephone Number
State how the beneficiary is related to you: Wife, Son, Daughter etc.
Your answer
Beneficiary's Address
Your answer
Relationship of Beneficiary
Your answer
Submit
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