Date of Application *

MM

DD

YYYY

Trip Selection *

Kenya (June 9 - June 18)

Kenya (August 14 - August 21)

Kenya (December 4 - December 16)

Name (as on passport) *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone *

(###)

###

####

T-Shirt Size

Small

Medium

Large

X - Large

XX - Large

XXX - Large

Gender *

Male

Female

Marital Status *

Single

Married

Engaged

Widow

Divorced

Do You Have an Up-to-Date Passport? *

Yes (complete the information below)

No

Yes

Name (as on passport) *

First Name

Last Name

Issue Date

MM

DD

YYYY

Expiration Date

MM

DD

YYYY

Previous Mission Trip Experience? *

Yes

No

Type of Trip

Evangelistic Outreach

Children/Youth

Medical

Humanitarian

Construction

Sports

Disaster Relief

Date of Most Recent Trip

MM

DD

YYYY

Work Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Work Phone

(###)

###

####

Facebook *

Yes

No

Instagram *

Yes

No

Do You Have An Ongoing and Active Walk of Faith In Christ Jesus? *

Yes, I Do

No, I Do Not

Do You Play An Instrument? *

Yes I Do

No I Don't

Do You Attend A Church? *

Yes

No

Physician's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Physician's Office Phone *

(###)

###

####

Health Insurance

Yes

No

Healthcare Provider Phone *

(###)

###

####

Are You Currently Taking Prescribed Medication

Yes I Am (please list below)

No I Am Not

Do You Have A Yellow Vaccination Card? *

Yes, I Do

No, I Do Not

Covid 19 Vaccination *

(non-vaccination does not disqualify you from a trip)

Yes, I Am Vaccinated

Yes, I Am Vaccinated and Boosted

No, I Am Not Vaccinated

First Emergency Contact *

First Name

Last Name

Cellphone *

(###)

###

####

Are They On Facebook? *

Yes

No

Second Emergency Contact *

First Name

Last Name

Cellphone *

(###)

###

####

Are They On Facebook?

Yes

No

Consent and Release *

I hereby agree to the performance of any medical treatment, including anesthetics deemed necessary by the attending physician in the event that I am unable to make these decisions for myself. I hereby release Youngstown Metro Assembly of God, Ohio, and all persons affiliated with this ministry from any liability arising from any injury, damage, or loss which may be sustained by me during my course of involvement with a short-term outreach trip. I also release Youngstown Metro Assembly of God, Youngstown, Ohio, from any liability for health impairment or bodily injury as a result of any pre-existing health condition. I will be responsible for monitoring and managing all aspects of any pre-existing condition.

I Understand and Accept

Non-Refundable Fee *

Are you able to immediately submit the $150 non-refundable application fee?

Yes, I Can Pay Now.

No, Not Right Now.

Financial Support Agreement *

I understand that any funds sent in for the aforementioned missions trips will not be reimbursed to me or the donor, per IRS regulations. In the case of a medical emergency that would prevent me from traveling I hereby agree to providing documentation to Metro Assembly of God and understand that I will receive reimbursement for the cost of the flight ticket only.

Yes, I Understand and Agree

Date Completed *

Acknowledgment of Financial Agreement

MM

DD

YYYY