Roca Blanca Missions Application
Foreign Visitor
* Required
Name
*
Email
*
Address
*
Home Phone
Work Phone
Birth Date
MM
/
DD
/
YYYY
Age
Sex
Male
Female
Height
Weight
Do you have a passport?
Yes
No
Passport Number
Marital Status
Single
Married
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
Speak
Translate
Read
Check one
Beginner
Intermediate
Fluent
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?
Excellent
Above Average
Good
Fair
Poor
Do you have or have you ever had diabetes?
Yes
No
Do you have or have you ever had seizures?
Yes
No
Do you have or have you ever had heart condition?
Yes
No
Do you have or have you ever had respiratory problems?
Yes
No
Do you have or have you ever had psychiatric care?
Yes
No
Do you have or have you ever had physical disability?
Yes
No
Do you have or have you ever had currently pregnant?
Yes
No
Do you have or have you ever had motion or altitude sickness?
Yes
No
Please explain any YES answers:
Are you presently under a doctor's care or taking medication?
Yes
No
If yes, explain below:
Do you have special diet requirements for medical reasons?
Yes
No
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 any and 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
MM
/
DD
/
YYYY
Parent/Guardian (if under 18)
Date
MM
/
DD
/
YYYY
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