MISSION TRIP APPLICATION
Central Community Church
Location and date of the trip for which you are applying:
Full Name as it appears on Passport:
Passport Number:
Expiration Date (mm/dd/yyyy):
Preferred Name:
Address: ______________________________________________________ City
____________________
Province: _______________________________ Postal Code ___________________
Home Phone: ___________________________________ Cell Phone:
Work Phone:
______________________________
E-mail:
Your date of birth (for insurance purposes: mm/dd/yyyy):
Emergency contact names, e-mail addresses, and telephone number(s) (Please submit at least one).
Periodic e-mails will be sent to these family members to update them while you are away on your
trip.
Name & Relationship
Home
Phone
E-mail Address
Cell Phone
Acknowledge the following by signing your initials:
____________ I agree to sign the Central Short Term Mission Covenant
____________ I agree to sign all risk forms included in this application.
____________ I will attend all short term mission team training sessions
____________ I will complete the Plan to Protect training Central requires before I travel
____________ I am able to raise / pay for the totality of this mission trip
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1.0 CENTRAL COVENANT
All team members and leaders who are part of CENTRAL sponsored trips are asked to sign the
following Covenant to ensure consistency in character and conduct.
• • • • • • • • • • • • • • • • I recognize and accept the following conditions which will further the usefulness and
safety of our short-­‐term mission. If accepted as a member of this outreach team, I agree
to:
Release and discharge the organizations and individuals which helped make these
arrangements, including CENTRAL, their agents, employees, officers, and volunteers, from
all claims, demands, actions, judgments, or executions that I have ever had, or now have,
or may have, or which my heirs, executors, administrators, or assigns may have or claim to
have, against these organizations, their agents, employees, officers, and volunteers, and
their successors or assigns, for all personal injuries, known or unknown, and injuries to
property, real or personal, caused by, or arising out of this journey. I intend to be legally
bound by this statement.
Adopt an attitude that I am on this team to try to understand the host culture, not to
convince them of my own viewpoint or style. I know that there are many different ways to
accomplish the same objective, and know that my way is not necessarily the best.
Abstain from making derogatory comments or arguments regarding people, politics,
sports, religion, race, or traditions.
Go as a servant-­‐disciple of Jesus Christ and will adopt that attitude when dealing with my
fellow team members and those I meet during the trip
Accept and submit to the leadership role and authority of the team leader and promise to
abide by his or her decisions as they concern this mission trip.
Acknowledge that by engaging in this journey, I am subjecting myself to certain risks
voluntarily, including and in addition to those risks that I normally face in my personal and
business life, including but not limited to such things as health hazards due to poor food
and water, diseases, pests, and poor sanitation; potential danger from lack of control over
local population; potential injury while working; and inadequate medical facilities.
Understand that our team's work is but a tiny speck on the bigger picture that our mission
partners are trying to accomplish. I promise not to be overly demanding, to do my best
not to offend or cause embarrassment for the local mission host, and to do my best to
help them attain their long-­‐ term goals.
Attend all team meetings and training, both prior to departure, during the mission trip and
after our return home.
Refrain from meddling, complaining, and obscene or insensitive humour. I realize that
others on my team, during the journey, and while onsite will look at me for an example of
how a Christian acts, and will not treat that responsibility lightly. I understand that travel,
especially to remote locations, can be difficult, and I promise to adopt a flexible attitude
and be supportive as plans may need to be changed. I understand that I must travel with
the rest of the team, unless other prior arrangements are made.
Regard the differing styles of worshiping with respect. I promise that where I see the
need, I will witness my faith, but without a superior, colonial attitude.
If a loved one or close companion is traveling with me, we agree to interact with all
members of the team, not just one another. I promise not to initiate or seek new romantic
relationships with team members during the trip.
Avoid any actions that might be perceived as amorous attentions toward indigenous
people I meet.
Remember we are the new Christians from another part of the world and will be watched
very closely. I will not take lightly this important responsibility of setting an example.
Refrain from giving gifts, such as money, clothes, jewelry, mp3players, etc. Although the
intent of the giver is good, the result after we leave has caused problems for our host, and
jealousy and bitterness amongst those locals who received no such largesse. If I feel
compelled to give a gift to someone I have met, I will consult first with the team leader
before I promise or give the gift, and I promise to let him or her make the final decision on
this matter. This covenant does not apply to the small fellowship tokens we will discuss
and have approved before leaving home.
Act as a servant-­‐disciple of the local pastor or mission organization. I will respect the
advice I am given concerning attire, eating and drinking, and other such traditions, which
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will help me to assimilate into the local community. I will not use alcohol or illicit drugs
during any part of my travel to and from the host location.
• I agree that in the event my conduct is considered so unsatisfactory that it jeopardizes the
success of the trip, and that mediation during the trip has failed to correct my behaviour,
that my services in connection with this mission shall end and I shall return home
immediately at my own expense.
• In signing below, I represent that I am 18 years of age or older, or my parent/guardian will
sign also, accepting the above conditions on my behalf.
PERSONAL COVENANT
If you are unable to submit and abide by all of the above conditions, PLEASE DO NOT SIGN
BELOW. It is better to acknowledge this now than to find out on the field. We take short-­‐term
missions seriously, thus the seriousness of this covenant.
If candidate is 18 years of age or older:
____________________________________
(Signature)
____________________
(Date)
If candidate is under 18 years of age, signature of parent or guardian:
____________________________________
(Signature)
____________________
(Date)
2.0 LIABILITY
Medical Insurance
For international trips, a part of the cost you are paying covers the purchase of out of country medical
insurance. While Central Community Church is not responsible for benefits paid under the insurance
plan, you are designating Central Community Church to file claims and communicate with the
insurance company if needed.
_____________
Initials
Health
I understand that the short term mission trip will require that all participants be physically and emotionally
able to endure very difficult, strenuous, and demanding conditions. A participant may be required to
furnish a statement from his/her physician that they are able to withstand the rigours of this trip. I
understand that I am responsible for obtaining immunizations as outlined by my physician or travel clinic.
Central Community Church also reserves the right to accept, decline, or retain any person as a member of
the mission trip at any time.
_____________
Initials
Trip Details
Central Community Church is acting only in the capacity of agent and facilitator in matters of
transportation and mission operations. Central Community Church assumes no responsibility for
injury, damaged or lost of property, or other losses/expenses caused by delays, sickness, quarantine,
airlines, other transportation companies, or from other individuals, companies, or circumstances not
controlled by Central Community Church. Central Community Church reserves the right to make
alterations in the itinerary. Central Community Church also reserves the right to accept, decline, or
retain any person as a member of the mission trip at any time.
_____________
Initials
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Cost of the Trip
I understand that the cost of this trip is promoted on an approximate value and that the price of this
trip is subject to change (such as currency fluctuation). I understand that I am responsible for these
additional costs. I understand I am responsible to cover all immunizations necessary for travel. I
understand that it is my sole responsibility to raise the funds necessary to participate on this trip. I
understand that I will not be refunded what is remitted into the office by cheque, cash, online, or any
other means etc. I understand that monies remitted are assumed spent on airline tickets, hotels,
transportation and cannot be refunded.
_____________
Initials
Travel Documents
I understand that I am responsible to obtain all necessary travel documents for the trip. I am also
responsible to cover the cost of these documents and carry them on my person at all times. I understand
that failure to produce valid travel documents during travel will cost me additional funds and limit my
ability to travel to destinations to, at, from all preplanned locations.
_____________
Initials
Risk
I understand that any mission trip includes an inherent level of explicit and implicit risk. Travel accidents,
sickness, and injuries are among these risks. Further, I have reviewed the information about the mission
trip country found on the Canadian Foreign affairs Web site (http://www.voyage.gc.ca/index-eng.asp I
knowingly accept the risks of participating in this mission trip and release Central Community Church from
any and all claims related to lost travel documents, accidents, sickness, and injuries I may sustain.
_____________
Initials
Kidnapping / Hostage Taking
Central Community Church (Central) will take all reasonable precautions, based on the knowledge
available of the risks in an overseas country or region, to protect team members, staff, donors, contractors
and volunteers travelling on Central Short Term Mission Trips from being kidnapped.
Central will make no concessions to terrorists. We will not negotiate for payment of ransom for the
release of hostages or prisoners.
Central will cooperate with the appropriate governmental agencies to ensure that all perpetrators of
violent acts against its short term team members, staff, donors, contractors working on behalf of Central,
or persons volunteering their time and talents to Central, are brought to justice.
All persons in Central who are, or who potentially will be, in areas of the world where hostage taking or
kidnapping is a risk, shall sign an agreement affirming they have read, accepted and understood this
policy. All such agreements signed by Central staff, Corporation members, contractors, donors and/or
volunteers will be held on file Central.
I, ___________________________________________________________, have read the policy
above and understand and accept all risks of being a victim of kidnapping, or held hostage while
travelling on a short term mission trip with Central. I also understand that in the event that I am held as a
hostage or a victim of kidnapping, Central will use every legitimate means to secure my release, but will
not make any concessions nor negotiate payment of ransom for my release. I hereby waive any
obligations on the part of Central, to make ransom payments in the event I am a victim of kidnapping or
held hostage. I understand and accept that this kidnap Policy and Agreement is consistent with, and shall
be governed by and construed in accordance with the laws of Canada
_____________
Initials
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Child Protection
I understand I must attend Central’s Plan to Protect child program, that includes a police check in
order to qualify to attend a short term mission trip with Central Community Church. Failure to
complete this program disqualifies me from participating. Additionally when I arrive internationally, I
may be required to attend a child protection workshop for access to mission sites.
_____________
Initials
Participation is a Privilege
Central Community Church also reserves the right to accept, decline, or retain any person as a member of
the mission trip at any time. All participants must be first approved by the Board of Directors of Central
Community Church in accordance with the constitution and current policies.
_____________
Initials
I agree to release Central from any liability connected to this short term mission trip.
____________________________________
(Signature)
____________________
(Date)
3.0 MISSION TRIP EXPERIENCE
Do you have a relationship with Jesus Christ? If so can you briefly describe it.
• • Have you ever gone on a Central Community Church mission trip? Yes No
Have you ever gone on a mission trip with another church or organization? Yes
No
If you have gone on a mission trip, briefly describe your involvement and where you served:
Sharing you story is very important, because it is a gift that God uses to reach others with His
grace and love. Please feel free to use the reverse side or additional page if more space is
needed.
What is your reason for wanting to go on this missions trip?
What are some personal goals that you want to achieve on this missions trip?
Are you willing to participate in all team building and training events over the next few months?
Yes
No
Flexibility is a primary pre-requisite for such a project as this. Do you feel you have this attribute? Yes
No
Summarize your educational and vocation training:
Summarize gifts you feel you can use on this trip:
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4.0 HEALTH QUESTIONS
Note: The short term mission trip will require that all participants be physically and emotionally able to
endure very difficult, strenuous and demanding conditions. A participant may be required to furnish a
statement from his/her physician that they are able to withstand these kinds of third world conditions.
Please note that answering yes to any of these questions does not necessarily disqualify you from a short
term missions trip, rather they are being used as a source of information to help us asses how to best
serve you on a missions trip.
Do you have any chronic or current health problems that might be affected by the environment and living
conditions in a third world country? Yes
No
If yes, please give a brief description:
Have you ever had any serious injury or illness?
If yes, please explain on a separate sheet.
Yes
No
Are you currently receiving medical treatment or evaluation on a regular basis?
If yes, please explain on a separate sheet.
Yes
No
Are you currently taking medication(s)? Yes No
If yes, please list with reason for usage on a separate sheet.
Do you use alcohol?
Yes No
Tobacco?
Yes No
Have you ever had, or have you now, any of the following? If yes, please explain.
Explain (if yes)
(1) Frequent and/or severe headaches Yes
No
(2) Dizziness or fainting
Yes
No
(3) Convulsions
Yes
No
(4) Nervous Breakdown
Yes
No
(5) Mental Problems
Yes
No
(6) Visual Problems Y
Yes
No
(7) Asthma
Yes
No
(8) Allergies
Yes
No
(9) Epilepsy
Yes
No
(10) Hearing Difficulties
Yes
No
(11) Heart Problems
Yes
No
(12) High/low Blood Pressure
Yes
No
(13) Breathing Problems
Yes
No
(14) Digestion Problems
Yes
No
(15) Back or Neck Problems
Yes
No
(16) Joint Problems
Yes
No
(17) Foot Problems
Yes
No
Do you have any special dietary needs?
Yes No
If yes please explain
_______________________________________________________________________
5.0 Church Recommendation
Do you belong to a church
Yes
No
If yes, which church do you belong to:
Address of Church:
City
Prov
Postal Code
Pastor:
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Church ministry in which you are involved: (Example: Sunday School teacher, usher / greeter etc.)
A recommendation from a Pastor is required. If you do not have a Pastor please connect with the
team leader and he/she will work with you on an individual basis:
I whole-heartedly recommend
faith and spiritually equipped to serve on this volunteer project.
Pastor
Name of Church
as sound in his/her
Date
Please print pastor’s name.
Thank you for completing this application. You will be contacted as soon as your application has
been approved by our Review Committee.
If you have questions please call 905-937-5610 ext248 or e-mail [email protected]
Please send this application to:
Jonathan Gallo
Central Community Church
240 Scott Street
St. Catharines, ON
L2M 7W7
This application must be submitted with the required deposit.
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