Application for Short-Term Mission Trip Participant

Your name *

Last name

Email address *

Address *

HomeWorkOther

Country

Country

Street address

Apt/unit/box (optional)

City

State

Postal code

Phone number *

Phone type

MobileHomeWorkOther

Birthdate *

Gender *

Select…MaleFemale

Marital status *

Select…SingleMarriedWidowed

Grade

Select…Pre-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th Grade

School

Select…

Shirt Size *

XS

S

M

L

XL

XXL

XXXL

PREVIOUS MISSION WORK: If you have done mission work before, please list the organization's name/address, country of mission work, dates of mission work, and service performed in the mission field. *

If no previous mission work, write "none"

CHURCH ACTIVITIES

Are you a member of Eastside Church? *

Yes

No

Unknown

If yes, what years have you attended?

If you are not a member of Eastside, are you currently attending another church? If yes, please list the church's name, pastor's name, years attended.

List the ministries with which you have been involved at Eastside Church (please include the length of service and any leadership positions held):

List the ministries with which you have been involved outside of Eastside Church (please include the time of involvement and any leadership positions held):

Please share your testimony, including how long you have been a believer. *

Please explain briefly what you hope to see the Lord do in and through you on this mission trip. *

REFERENCES:

Please provide three references. The references should be someone who knows your ministry abilities as well as your strengths and weaknesses.

Reference 1 (Include their name, relationship to you, and phone number): *

Reference 2 (Include their name, relationship to you, and phone number): *

Reference 3 (Include their name, relationship to you, and phone number): *

HEALTH QUESTIONNAIRE AND MEDICAL CONSENT

Place of Birth: *

Name of Emergency Contact: *

Relationship of Emergency Contact with Applicant: *

Address of Emergency Contact: *

Emergency Contact Daytime Phone: *

Emergency Contact Evening Phone: *

Email Address of Contact: *

If Applicable, list the name of your spouse (if not emergency contact):

HEALTH INFORMATION:

Height: *

Weight: *

Blood Type:

Describe your general health: *

Good

Average

Poor

Name and Phone # of Participant's Doctor: *

Please list any medical conditions including allergies of which a medical care provider should be aware (if none, write "none"). *

Please list any prescribed medication taken on a regular basis (if none, write "none"): *

Please list any dietary restrictions or food allergies (if none, write "none"): *

Please list any other medical information that you believe is important (if none, write "none"): *

Is participant covered by personal/family insurance? *

Yes

No

If yes, name of insurer, along with policy or group number:

Submit

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