Roca Blanca Missions Application
Foreign Visitor
* Required
Name
*
Your answer
Email
*
Your answer
Address
*
Your answer
Home Phone
Your answer
Work Phone
Your answer
Birth Date
MM
/
DD
/
YYYY
Age
Your answer
Sex
Male
Female
Clear selection
Height
Your answer
Weight
Your answer
Do you have a passport?
Yes
No
Clear selection
Passport Number
Your answer
Marital Status
Single
Married
Clear selection
Number of Children
Your answer
Parent's or Spouse's Name
Your answer
Parent's or Spouse's Phone
Your answer
In case of emergency contact
Your answer
Relation to you
Your answer
Home Phone
Your answer
Work Phone
Your answer
What languages are you able to communicate in and in what capacity?
Your answer
Check all that apply
Speak
Translate
Read
Check one
Beginner
Intermediate
Fluent
Clear selection
What church do you attend?
Your answer
Church Address
Your answer
Church Phone Number
Your answer
Pastor
Your answer
E-mail
Your answer
How long have you attended?
Your answer
How long have you been a Christian?
Your answer
How would you rate your physical condition?
Excellent
Above Average
Good
Fair
Poor
Clear selection
Do you have or have you ever had diabetes?
Yes
No
Clear selection
Do you have or have you ever had seizures?
Yes
No
Clear selection
Do you have or have you ever had heart condition?
Yes
No
Clear selection
Do you have or have you ever had respiratory problems?
Yes
No
Clear selection
Do you have or have you ever had psychiatric care?
Yes
No
Clear selection
Do you have or have you ever had physical disability?
Yes
No
Clear selection
Do you have or have you ever had currently pregnant?
Yes
No
Clear selection
Do you have or have you ever had motion or altitude sickness?
Yes
No
Clear selection
Please explain any YES answers:
Your answer
Are you presently under a doctor's care or taking medication?
Yes
No
Clear selection
If yes, explain below:
Your answer
Do you have special diet requirements for medical reasons?
Yes
No
Clear selection
If yes, explain below:
Your answer
Doctor's care or medication explanation:
Your answer
Special diet requirements for medical reasons explanation:
Your answer
I, the undersigned and we, the parents or legal guardians and/or custodians of the undersigned (if a minor), give permission for the undersigned participant to go on a short-term mission project under the leadership of Victory Latin American Outreach (Roca Blanca Missions Base), and HEREBY RELEASE AND AGREE TO HOLD HARMLESS Roca Blanca Missions and their officers, employees, agents, and servants, from any liability whatsoever that might occur to the undersigned, as the result, whether immediate or proximate or not, due to my participation in the short-term mission project sponsored by the above mentioned party. I specifically agree to personally provide all insurance policy protection that may be necessary, helpful, or desirable for my participation and I will not rely upon Roca Blanca Missions. for such protection.
Participant's Signature:
*
Your answer
Date
MM
/
DD
/
YYYY
Parent/Guardian (if under 18)
Your answer
Date
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. -
Terms of Service
-
Privacy Policy
Forms