Roca Blanca Missions Application
Foreign Visitor
* Required
Name
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Email
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Address
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Home Phone
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Work Phone
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Birth Date
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Age
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Sex
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Height
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Weight
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Do you have a passport?
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Passport Number
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Marital Status
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Number of Children
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Parent's or Spouse's Name
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Parent's or Spouse's Phone
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In case of emergency contact
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Relation to you
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Home Phone
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Work Phone
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What languages are you able to communicate in and in what capacity?
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Check all that apply
Speak
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What church do you attend?
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Church Address
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Church Phone Number
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Pastor
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E-mail
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How long have you attended?
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How long have you been a Christian?
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How would you rate your physical condition?
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Do you have or have you ever had diabetes?
Yes
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Do you have or have you ever had seizures?
Yes
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Do you have or have you ever had heart condition?
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Do you have or have you ever had respiratory problems?
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Do you have or have you ever had psychiatric care?
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Do you have or have you ever had physical disability?
Yes
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Do you have or have you ever had currently pregnant?
Yes
No
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Do you have or have you ever had motion or altitude sickness?
Yes
No
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Please explain any YES answers:
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Are you presently under a doctor's care or taking medication?
Yes
No
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If yes, explain below:
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Do you have special diet requirements for medical reasons?
Yes
No
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If yes, explain below:
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Doctor's care or medication explanation:
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Special diet requirements for medical reasons explanation:
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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:
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Date
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Parent/Guardian (if under 18)
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Date
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