Mission Application Form

First Name: [Exactly as it appears on your passport] *

Last Name: [Exactly as it appears on your passport] *

Home Phone *

Mobile Phone *

Preferred Email Address *

Passport Number *

Date of Birth *

Issue Date *

Nationality *

Expiration Date *

Street *

City *

State *

Zip code *

Gender *

Male

Female

If married, name of spouse *

Names and DOB of Children (if any)

Name *

Relationship to you *

Address *

Phone Number *

Mobile Phone Number *

Name *

Relationship to you *

Address *

Home phone number *

Mobile Phone Number *

Do you have any medical concerns that we should be aware of? *

Yes

No

Please explain

Do you have any allergies we should be aware of? If yes please explain. *

Yes

No

Please explain

Do you have medical Insurance? *

Yes

No

Do you have travel insurance? *

Yes

No

Name of health insurance company *

Health insurance phone number *

Name of Primary Physician *

Primary physician's phone number *

Medical Release: In the case of an emergency, I hereby authorize ACF-East Region to obtain and provide such medical advice and services as deemed necessary by the Team Leader. I agree to the performance of such treatment, including anesthesia and surgery, as determined by the attending physician or health care professional. I accept responsibility for all medical costs that may exceed the coverage provided by my health care plan.

Full Name *

Have you ever been on a short-term mission trip before?*

Yes

No

Please explain what, where, when and with what organization.

If you have been on a previous mission trip, what was your most significant contribution? *

What are your personal strengths? *

What church are you affiliated with? *

What ministries are you currently involved in at your church? *

Do you belong to a local chapter of African Christian Fellowship (ACF)? *

Yes

No

What is your involvement in your local ACF Chapter? *

Please indicate any ministry gifts, talents, interests, skills, or specific experiences that you feel may be helpful to the team during this mission trip. *

What is your primary inspiration for applying for this year’s mission trip? *

Please state three particular activities you are most interested in participating in: *

What countries would you prefer to be assigned to? [Please note that we will try to accommodate your country and activity preferences as far as possible but the final decision will be based on what’s best for the team as a whole.] *

Uganda

Benin

Are you willing to forego personal preferences to honor your team members and those you will be ministering to? *

Certainly

Most Likely

Perhaps

Not Really

Please explain briefly what you expect to see the Lord do in and through you during this mission trip? *

How do you plan to apply the experience and lessons from this mission trip? *

Name *

Address *

Name *

Address *

Release of Liability and Specific Limitations: I understand that there are certain risks inherent in overseas travel and my participation in this short- term mission trip to Africa, including but not limited to weather conditions, illness, accident or injury; and the potential lack of accessible, desirable or effective medical care. Team members, leaders and other volunteers serve at their own risk. I hereby release ACF-East Region., its leadership and volunteers from any and all liabilities arising out of any injury, damage or loss which may be sustained by me during the course of my involvement in the mission trip including preparation thereof. I am aware that ACF-East Region. will do whatever is within its organizational limit to ensure the safety of all team members. The mission trip experience could entail intense physical activities including continuous walking that require good physical condition. I understand that activities during the mission trip are often done in groups, and that all team members are expected to participate fully as directed by the Team Leader. As a Christian organization, ACF Missions expects team members to honor the Lord by a Christian lifestyle that is consistent with the Bible. As we seek to serve the Lord by serving those He has sent us to, we endeavor to model Christ before them. Therefore all team members are required to avoid any inappropriate relationship with persons of the opposite gender or any appearance of this. Team members are expected to adhere to all instructions given by the Team Leader and follow guidance in the interest of team cohesion. Continuous disruptive behaviors, which affect the experience or compromise the safety of other team members, may result in such team member being advised to return home at their own expense. ACF-East Region. or its volunteers and leadership will not be responsible for the lost or damage to any personal property of team members. Any valuable items should be left at home. I understand that travel dates, schedules and country of ministry are subject to change. In the event that a trip is cancelled, for any reason, ACF-East Region will assign team members to another trip. Every team member is expected to raise a total of $3,000.00 for the missions’ trip, to cover the cost of airfares and execution of the missions work (accommodation, feeding etc) in the missions’ field. If an individual is unable to participate in the trip, funds raised, less incurred expenses and administrative fees, will be credited to the next trip. If the individual is not able to go on the next mission trip, ACF-East Region will not be able to keep the money beyond one year, and will use the money to support its missions work. I agree to attend the team meetings, training sessions, debriefing, and to participate in other post-trip informational meetings. I agree I will do my best to work towards achieving the goals of the mission trip. By signing below, I confirm that information I have provided herein is accurate and true to the best of my knowledge and that I agree with all the limitations stated above.

Full Name *