International Mission Application
Short term mission team application
Email address *
Name as it appears on Passport (or as it will appear if not yet received) *
Your answer
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
Your answer
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
Your answer
Emergency Contact Number
Your answer
Emergency Contact Email
Your answer
Emergency Contact Relation
Your answer
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
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 five 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 *
Your answer
Beneficiary Relation to you *
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 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?
Enter your name as your signature. *
Your answer
If you are under 18 your parent(s) must enter his or her name(s) below as his/her signature(s).
Your answer
Do you consent to us keeping your information on a secure external drive for subsequent trips? *
Submit
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