ETHIOPIA SHORT TERM MISSION TRIP OCTOBER 2014

Transcription

1 ETHIOPIA SHORT TERM MISSION TRIP OCTOBER 2014 Completion of this application does not necessarily guarantee a place on the mission trip. Each application will be reviewed by the Missions Director and/or the Team Leader for the trip. SHORT TERM TRIP APPLICATION (one per person) + answers to 5 narrative questions. SIGNATURES OF AGREEMENT $100/PERSON DEPOSIT (payable by check made out to Trinity OR on-line at - Ministries/Trinity Outreach/Trip Opportunities) COLOR COPY OF PASSORT - 1 ST two pages/photo page, for each person (Note: If your passport expires before MARCH 2015, it will need to be renewed before this trip) TRINITY MEDICAL & LIABILITY RELEASE FORM (one per person complete form appropriate to your age) This packet is due to the Mission/CE office by. You will hear back about the status of your application by. Please drop off or send your completed application packet to the Trinity CE Office, ATTN: Janis Kerr. For information, Janis@tupcsa.org.

2 PERSONAL DATA: TRINITY UNITED PRESBYTERIAN CHURCH SHORT-TERM TRIP APPLICATION Name (as it appears on your passport): Address: City: State: Zip: Telephone: (home) (cell) Gender: Male Female Birthdate: / / Birthplace: PASSPORT INFORMATION: If you do not have a passport, or if you passport expires before February 2015, please apply for one/apply for renewal as soon as you hear that you have been accepted on this trip. Please submit the information requested below immediately after receiving a passport. Date of Issue: Place of Issue: Passport Country & Number: Expiration Date: Birthplace: Note: Attach a copy of your passport to this packet and submit to the Missions & CE Office. HEALTH INFORMATION: Trinity requires that each short-term mission team member have travel insurance. Some mission trips may have travel insurance included in the cost. Your team leader will inform you if you need to purchase travel insurance separately. General Health: Excellent Good Fair Do you have any allergies? Yes No Physical challenges? Yes No Dietary restrictions? Yes No Emotional challenges? Yes No If yes, explain below. Use an additional sheet if necessary. Are you currently under a physician s care and or receiving prescribed medication of which we should be aware? Yes No If yes, please explain and list medications: Page 1 of 3

3 Are you covered by illness and accident insurance? Yes No Does it cover out of state/country travel? Yes No Name of your insurance Company: Policy Number: Emergency Insurance Contact Number: Are there any other special considerations we should know about in processing your application? If so, please list: In case of emergency, please notify: Name: Relationship: Address: City: State: Zip: Home Phone: Cell: Check any of the skills below that apply to you. Give further explanation if necessary: Construction Carpentry Masonry Plumbing Electrical Medical Doctor Nurse Dentistry Nutrition Other Business Accounting Management Marketing Personal Ministry Bible Study Leader Evangelism Singing (soloist) Musical Instrument Children VBS Other Horticulture Agriculture Arts/Crafts Food Service Other: Computer Programming Data Entry Word Processing Second Languages: List any languages other than English you can speak and your proficiency level: On a separate sheet of paper please answer each of the following: 1. Why do you want to go on this trip? 2. What are the realistic roadblocks that might keep you from going? 3. Have you gone on any short-term teams before? 4. Which staff member or ministry leader knows you well? 5. Please describe your faith journey. Page 2 of 3

4 SIGNATURES OF AGREEMENT Please sign the three sections below and return to Trinity s Mission Department along with your Short Term Trip Application and Medical /Liability Release Form. Financial Agreement I understand that in attending this trip I am responsible for full payment. Any funds raised above the required trip costs will go toward the overall team expenses. If for any reason I am unable to fulfill the commitment to go on the mission trip, I will be responsible for all pre-paid expenses incurred on my behalf (i.e. airfare, lodging, training expense, etc.). Should this be the case, it is my responsibility to communicate to my donors regarding my inability to participate in the mission and to assure them that the funds will be used for the intended mission trip by the team. By signing this agreement I affirm the paragraph above and note that I have read through the Mission Trip Financial Policy (see page 2 of the Short Term Mission Trip: Team Member Information Packet) and agree to adhere to the guidelines. Signature: Date: Signature of Parent/Legal Guardian (if participant is under 21) Personal Covenant In signing below, I indicate that I have read, understood and accepted all of the conditions outlined in the Personal Covenant for Short Term Mission Trips with Trinity (see page 4-5 of the Short Term Mission Trip: Team Member Information Packet) Signature Signature of Parent/Legal Guardian (if participant is under 21) Date: Volunteer Waiver As a volunteer for a Trinity Mission Ministry Activities, I understand, acknowledge, and agree to the following: 1. Participation may include travel to and work in areas of the world characterized by hazardous conditions, possibly including risks such as land mines and unexploded ordinances, sniper fire, unstable governance and security, damaged buildings, exposed electrical wiring, contaminated food and water, disease, and poor medical care. Furthermore, in light of recent acts of terrorism in the United States, the State Department has issued a public announcement, dated September 12, 2001, entitled, Worldwide Caution, in which U.S. citizens are urged to maintain a high level of vigilance and to increase their security awareness while traveling abroad. The public announcement further warns that U.S. citizens may be targets of terrorist acts. 2. My life and medical insurance coverage may have exclusions for death, illness, or injury occurring in high warrisk or international destinations. I acknowledge that I am responsible for and have been advised to acquire appropriate travel or war-risk life and health insurance for the duration of the project activity and that I am responsible for my own medical and life insurance coverage. 3. I understand and hereby fully assume all risks and liabilities which may result from my participation as a volunteer. I release and forever discharge and hold harmless Trinity United Presbyterian Church, it s employees, representatives, and agents from any and all actions, claims, and liabilities arising out of injury to or damage sustained by me. Further, in the event of injury to me, I hereby consent to and authorize medical treatment and tests considered advisable or necessary in the judgment of any qualified medical personnel. Signature: Date: Signature of Parent/Legal Guardian (if participant is under 21) Page 3 of 3

5 MEDICAL AND LIABILITY RELEASE FORM COLLEGE/ADULT Trinity United Presbyterian Church Prospect Ave. Santa Ana CA (714) Name Last First Birthdate Age (in Fall 2014) Address Street and Number City Zip Student's Home Phone Male Female Father Phone H ( ) W ( ) Cell ( ) Mother Phone H ( ) W ( ) Cell ( ) In Emergency, Notify: Phone ( ) Doctor Phone ( ) Allergic reactions: Drugs Insect stings Other If you have checked any of the above, please give details (i.e., include normal treatment of allergic reactions). Date of last tetanus shot: Medications: Name: Dosage/ Times: Any swimming restrictions Yes No Any activity restrictions? Yes No Please explain if answer was yes Our church's insurance is only secondary insurance. If you have medical insurance, your carrier will be billed for medical charges in the case of illness or injury while your son or daughter is on a church-related activity. Do you have health insurance? Yes No Insurance Company Policy Number MEDICAL RELEASE "In the event that I cannot be reached in an emergency during the dates specified on this form, I hereby give my permission to the physician or dentist selected by the church leadership to secure proper intervention, X-ray examination, medical or surgical diagnosis and treatment, anesthesia, and hospitalization for my son or daughter as deemed necessary. I authorize church staff or volunteer staff to give the following generic, over- the-counter medications as directed by the labels provided by the manufacturer for my child: Analgesics (ibuprofen or acetaminophen), antihistamines (Sudafed, Benadryl, etc) antibiotic ointment, hydrocortisone cream (such as Cortaid), electrolyte replacement fluids (such as Gatorade), antiseptic skin and wound cleansers, analgesic balms or gels, sunscreens, with the exception of: LIABILITY RELEASE Every activity sponsored by this church is carefully planned and adequately supervised by mature adults. However, even with the best planning and precautions, unforeseen events can occur. By signing this form the parent or guardian agrees to assume and accept all risks and hazards inherent in church-related social activities. They also agree not to hold this church (TUPCSA) or its employees or volunteer assistants liable for damages, losses or injuries to the person or property undersigned. The parents or guardians understand that they are signing for the minor listed on this form and the signature is for both a medical and liability release. By signing this form, I am authorizing permission for my photo to be used in Trinity publicity. Parent or Guardian s signature if UNDER 18 years old: IF OVER 18 YEARS OLD SIGN BELOW: Mother/Father Guardian Date Signed Valid from May 1, 2013 to June 30, 2015 IMPORTANT: Rev. 3/12 Please notify the Family Ministries Office (714/ ext 101 or 119) if your student is exposed to any communicable diseases during the three weeks prior to camp attendance.

6 MEDICAL AND LIABILITY RELEASE FORM CHILDREN Trinity United Presbyterian Church Prospect Ave. Santa Ana CA (714) Name Last First Birthdate Grade (in Fall 2014) Address Street and Number City Zip Student's Home Phone Male Female Father Phone H ( ) W ( ) Cell ( ) Mother Phone H ( ) W ( ) Cell ( ) In Emergency, Notify: Phone ( ) Doctor Phone ( ) Allergic reactions: Drugs Insect stings Other If you have checked any of the above, please give details (i.e., include normal treatment of allergic reactions). Date of last tetanus shot: Medications: Name: Dosage/ Times: Any swimming restrictions Yes No Any activity restrictions? Yes No Please explain if answer was yes Our church's insurance is only secondary insurance. If you have medical insurance, your carrier will be billed for medical charges in the case of illness or injury while your son or daughter is on a church-related activity. Do you have health insurance? Yes No Insurance Company Policy Number MEDICAL RELEASE "In the event that I cannot be reached in an emergency during the dates specified on this form, I hereby give my permission to the physician or dentist selected by the church leadership to secure proper intervention, X-ray examination, medical or surgical diagnosis and treatment, anesthesia, and hospitalization for my son or daughter as deemed necessary. I authorize church staff or volunteer staff to give the following generic, over- the-counter medications as directed by the labels provided by the manufacturer for my child: Analgesics (ibuprofen or acetaminophen), antihistamines (Sudafed, Benadryl, etc) antibiotic ointment, hydrocortisone cream (such as Cortaid), electrolyte replacement fluids (such as Gatorade), antiseptic skin and wound cleansers, analgesic balms or gels, sunscreens, with the exception of: LIABILITY RELEASE Every activity sponsored by this church is carefully planned and adequately supervised by mature adults. However, even with the best planning and precautions, unforeseen events can occur. By signing this form the parent or guardian agrees to assume and accept all risks and hazards inherent in church-related social activities. They also agree not to hold this church (TUPCSA) or its employees or volunteer assistants liable for damages, losses or injuries to the person or property undersigned. The parents or guardians understand that they are signing for the minor listed on this form and the signature is for both a medical and liability release. By signing this form, I am authorizing permission for my child s photo to be used in Trinity publicity. Parent or Guardian s signature: Mother Father Guardian Date Signed Valid from May 1, 2013 to June 30, 2014 IMPORTANT: Please notify the Family Ministries Office (714/ ext 101 or 119) if your student is exposed to any communicable diseases during the three weeks prior to camp attendance. Rev. 3/13