Name *

First Name

Last Name

Gender *

Male

Female

Birth Date *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone *

(###)

###

####

Will your phone be reachable while on the campaign? (international plan)

Yes

No

Home Phone

(###)

###

####

Emergency Contact *

First Name

Last Name

Emergency Phone *

(###)

###

####

Emergency Medical Treatment Consent/Release *

While traveling with Latin American Missions, I do hereby expressly consent that I or my child may receive emergency medical treatment from any physician, hospital, or other medical center without the necessity of first notifying me, and do further agree to hold blameless any Latin American Missions staff member, physician, hospital or other medical center for rendering such services and that I am responsible for any expenses incurred as the result of such medical treatment. By checking "Yes" I agree with the Emergency Medical Treatment Consent/Release statement above.

Yes

No

Passport Expiration Date

MM

DD

YYYY

If you do NOT have a current passport, list the date you applied for one.

MM

DD

YYYY

Are you a member of the Church of Christ?

Yes

No

Do you speak Spanish?

Yes - Fluent

Yes - Some

No - not enough to translate

Are you a licensed Medical Professional?

NOTE: Medical Professionals must send a *clear copy of your (1) Diploma, (2) Resume and (3) License, which must be in-date during the campaign. Most all of the host countries are now requiring medical licenses be in country 60 days prior to the campaign date. For all Medical Professionals working in El Salvador, an apostille is required. * New official medical documents show a "\void\" when copied. Please make readable copies without the "\void\".

Yes

No

Do you have any of the following special training, skills, or experience?

Conducting Evangelistic Bible Studies

Teaching Bible Classes

Teacher's Helper

Door Knocking

Translating; Spanish/English

Carpentry

Electrical

Plumbing

Masonry

Painting

Food Preparation for Large Groups

Physician/PA/Nurse Practitioner (prescriber)

Nursing

Have you ever participated in a Latin American Missions campaign?

Yes

No

FLIGHT ARRANGEMENTS: Check below if you need to make your own flight arrangements apart from the group.

I will make my own flight arrangements

Who is paying for your flight expenses?

Myself

My Congregation

Shared Team Expenses will be paid by:

Myself

My Congregation

Scholarship (Kirk will have notified you by email)

I am on an HCU/LAM Scholarship

I have read, understand and certify the information contained in this application is true and accurate to the best of my knowledge. *

I UNDERSTAND

I understand that I must send a non-refundable $100 reservation deposit to Latin American Missions before 90 days prior to the start of my selected campaign or my reservation will be canceled. *

I UNDERSTAND

I understand that this registration is subject to the approval or denial of the elders of the Forrest Park church of Christ. *

I UNDERSTAND