Roca Blanca Missions Application
Foreign Visitor
Name *
Email *
Address *
Home Phone
Work Phone
Birth Date
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Age
Sex
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Height
Weight
Do you have a passport?
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Passport Number
Marital Status
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Number of Children
Parent's or Spouse's Name
Parent's or Spouse's Phone
In case of emergency contact
Relation to you
Home Phone
Work Phone
What languages are you able to communicate in and in what capacity?
Check all that apply
Check one
Clear selection
What church do you attend?
Church Address
Church Phone Number
Pastor
E-mail
How long have you attended?
How long have you been a Christian?
How would you rate your physical condition?
Clear selection
Do you have or have you ever had diabetes?
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Do you have or have you ever had seizures?
Clear selection
Do you have or have you ever had heart condition?
Clear selection
Do you have or have you ever had respiratory problems?
Clear selection
Do you have or have you ever had psychiatric care?
Clear selection
Do you have or have you ever had physical disability?
Clear selection
Do you have or have you ever had currently pregnant?
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Do you have or have you ever had motion or altitude sickness?
Clear selection
Please explain any YES answers:
Are you presently under a doctor's care or taking medication?
Clear selection
If yes, explain below:
Do you have special diet requirements for medical reasons?
Clear selection
If yes, explain below:
Doctor's care or medication explanation:
Special diet requirements for medical reasons explanation:
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: *
Date
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Parent/Guardian (if under 18)
Date
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