Application Form For Short Term Trips

Please enclose 2 passport sized photos

MISSION DIRECT SHORT TERM MISSION TRIP APPLICATION FORM Please print clearly (in black)

We appreciate that if you have previously been on a trip with us you will have supplied much of this information before; however we would request that you complete this in full in order for us to maintain accurate records. Please do not hesitate to call us with any queries or questions concerning this form or the trip on (01582) 720056.

APPLICANT PERSONAL DETAILS Surname

Title

First Name(s) (As on Passport)

Preferred name for name badge (James = Jim)

Marital status

Address Postcode Home phone

Work phone

Mobile

Email Address Please tick if you do not want us to share your email address with other team members □ Male /Female

Age

Date of Birth

Occupation

Citizenship

Have you travelled with Mission Direct before?

If yes when and where?

How did you hear of Mission Direct?

TRIP DETAILS – Which trip are you applying for? Country

Have you been to this country before?

Preferred dates

Alternative dates

PASSPORT DETAILS Passport Number

Place of Issue

Date of Issue

Place of Birth

Expiry Date

NOTE:- YOUR PASSPORT MUST HAVE 6 MONTHS VALIDITY AFTER RETURN TRAVEL DATE

For Office Use Only

Rec’d

Mission Trip Application Form 07 Version 1

Deposit

Complete

Contact

CHURCH LEADER REFERENCE If you regularly attend a church please ask your church leader to complete this section and get him/her to sign where indicated. If you do not regularly attend a church please leave blank.

Name

Phone Number

Church Name

E-mail

Address Postcode Comments

I approve this application.

Signed

Date

EMERGENCY CONTACT DETAILS This person may give consent for medical treatment if I am unable to do so

Name

Relationship

Home phone

Work phone

Mobile

E-mail Address Postcode Mission Direct is unusual in that you do not have to be skilled to come. However, it helps us to know if you are skilled or gifted in certain areas. Please could you let us know any skills you have e.g. overseas experience, photography, leading worship, accounting, writing, construction, welding, DIY, electrical etc; (please add additional paper if necessary)

SPECIAL REQUIREMENTS Please give details below of any special requirements regarding dietary needs, accommodation, flight seats etc.

T-shirt size (Please circle)

S

Mission Trip Application Form 07 Version 1

M

L

XL

XXL

MISSION DIRECT MEDICAL INFORMATION PRINT NAME Your medical information is an important part of the application. We do not determine your physical or emotional preparedness to serve. This is your responsibility and you must consult with your doctor to determine your readiness and make arrangements for your health and physical requirements without relying on any action before, during or after the time of service with Mission Direct or anyone connected with them. In certain circumstances, Mission Direct may also ask you to provide a consent letter from your doctor before accepting your application. Travel & medical insurance which includes the cost of medical treatment and emergency airlift is required for each participant of a Mission Direct team and is included in your contributions. Any pre-existing conditions will need to be assessed before insurance cover is issued. Do you suffer from any of the following? Please tick the ‘yes’ or ‘no’ box as appropriate: Yes

No

Yes

No

Anaemia

Fainting / Blackouts / Dizziness

Arthritis

Frequent infections

Asthma

Heart Disease / Angina

Back Strain / Pain / Problems

Hepatitis / Jaundice / Liver Problems

Blood Clotting or Bleeding Disorder

High or Low Blood Pressure

Cancer / Recent Chemotherapy

Kidney Problems / Stones

Chronic or Excessive Fatigue

Severe or Migraine Headaches

Depression / Sleep Disorder

Shortness of Breath

Diabetes (Type 1 or 2) Emotional/Mental/Nervous Breakdown or Disorders Epilepsy / Seizures Have you had any surgery within the last six months?

Stomach or Duodenal Ulcer

Have you ever had an injury or health problem that has substantially limited or restricted your lifestyle or work capacity?

Have you ever had any significant illness or injury other than those already noted?

Any medical condition that is currently, or has in the last 5 years been treated by a physician, chiropractor or healer?

Do you require the use of any braces, prosthesis, supportive devices or aid to do your job or activities of daily living?

Stroke Vision loss not corrected by glasses Have you had a baby within the last six months?

Ladies only – Are you pregnant? Any other relevant medical factors?

If you have answered ‘Yes’ to any of the above questions or you are currently under the care of a doctor, please give full details here or on a separate sheet and attach to this page.

Mission Trip Application Form 07 Version 1

MISSION DIRECT MEDICAL INFORMATION (Continued) Please list all known food and drug allergies.

Please state any dietary requirements e.g. Vegetarian, Nut/Spices/Wheat intolerance etc.

Please list all medication you are currently taking. Name

Dosage

Frequency

DECLARATION 1) I confirm I will have adequate supplies of medication(s) for the duration of my trip. (Please circle)

YES

NO

N/A

2) I confirm this is an accurate account of my State of Health.

Signature

MISSION DIRECT

Mission Trip Application Form 07 Version 1

Date

Mission Direct projects are in developing countries. Such locations may have access only to unconventional modes of transportation, communication and accommodation. Team participants may experience inconveniences resulting from international travel, illness, and cultural differences. Because of the trip’s nature, Mission Direct asks that each participant understand and execute the following liability release and indemnity.

RELEASE OF LIABILITY AND INDEMNITY I and all members of my family, accept the risks and responsibilities associated with my Mission Direct trip. I hereby agree to release Mission Direct, their directors, officers, agents, members, employees, representatives, successors and assignees from any and all claims, liability, loss, expense, costs and proceedings in respect of personal injury or illness or property that might arise from my outreach with Mission Direct. I understand that travelling to and from the location that I am working in, is my responsibility and Mission Direct shall not be liable for any accidents, sickness or injuries during this travel or on location with the Mission Direct programme. I agree to indemnify Mission Direct from and against any such claims, liability, loss, expense, costs and proceedings. If I require any medical attention I understand that Mission Direct is not responsible for treatment. If however, Mission Direct staff, decide to render aid, I give permission for whatever treatment is deemed medically necessary by Mission Direct staff whether at a local clinic, or other location. The laws of England and Wales shall govern this release of liability and indemnity. I have read, understood and agreed with all of the above. PARTICIPANT (PRINT NAME) Signature

Date

WITNESS (PRINT NAME) Witness address Postcode Witness signature

Date

GIFT AID DECLARATION We can now claim back tax against all your donations since 6 April 2000; provided you are a UK taxpayer. If you would like to make your donations worth more – at no cost to you – please complete the details below. For this Gift Aid Declaration to be valid, you must pay at least as much UK tax as the amount claimed. If your circumstances change please inform us. Name Address Postcode Signature

Date Mission Direct is a Company Limited by Guarantee No. 5289161 – Registered Charity No. 1107824. Website: www.missiondirect.org Address: Mission Direct, 6B Britannia House, Leagrave Road, Luton, LU3 1RJ. Tel: (01582) 720056. Fax: (01582) 720144 E-mail: [email protected] .

PLEASE SEND THIS FORM WITH YOUR £100 DEPOSIT TO THE ABOVE ADDRESS. PLEASE MAKE CHEQUES PAYABLE TO MISSION DIRECT.

Mission Trip Application Form 07 Version 1