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Trip of Interest:

The Rock Outreach, Inc. APPLICATION FOR SHORT-TERM MISSION TRIP Date: GENERAL INFORMATION

Name (as it appears on your passport) Address: City: Home Phone: Occupation: Social Security Number:

Last:

First:

Middle:

State: Work Phone: E-mail:

ZIP:

Male Female Yes No

Single Married

Are you a member of a church: Name?

If yes, how long have you attended:

TRAVEL INFORMATION You need to apply for a passport as soon as possible if: You do not have a passport, or Your current one expires within six months of your return from this trip.

If you are in the process of obtaining your passport let us know this information as soon as you know it. Passport Number: Citizenship: Date of Issuance: Date of Birth: Date of Expiration: Place of Birth: EMERGENCY CONTACT INFORMATION Name: Home Phone: E-mail address: Relationship: Work Phone:

HEALTH QUESTIONS Do you have any particular health problems: Yes No Describe any health problems or risks: List medications: List any chronic disease or allergies you have: INSURANCE INFORMATION Company name: Group Number: Name of Insured: FIELD MINISTRY EXPERIENCE Do you speak a foreign language: Yes No Have you previously been on any short-term mission trips: Yes No Language speaking proficiency: Good Fair Cloudy If yes, where and when: 1. 2. If you have been on a trip previously, would you be willing to give up your place on a shortterm team for someone who has never been? Yes No Have you traveled outside the U.S.? Yes No 3. If No, please explain: Phone Number: Policy Number: If yes, do you have a Physician Release: Yes No

If yes, where: 1. 2. 3. Which ministries have/are you involved in and for how long? 1. 2. 3.

Are you now involved in a ministry at your church? Yes No

What are your spiritual gifts?

How well do you deal with uncertainty and change?

How would you rate yourself in flexibility and adaptability? Would you be willing to forego personal preferences to honor the culture in which you are going? Briefly describe any major life changes you have undergone in the last year (for example, job or family changes, death of a relative or close friend):

On a separate sheet of paper, please answer the following questions and return with the shortterm trip application: 1. How did you become a Christian? 2. What do you hope the Lord will do in and through you on the mission trip? 3. How do you expect your life to be different after the trip? CHRISTIAN EDUCATION Please indicate if you have completed any of the following: Bible college degree Bible Training Centre for Pastors (BTCP) Bible Study Fellowship (BSF) Precepts Bible Study Methods Evangelism Explosion Vision for the Nations Day of Discovery Seminary degree or classes Bible Education by Extension (BEE) Perspectives Real Faith Discipleship Child Evangelism Unveiling Glory Other

If you have checked any of the above, please explain:

REFERENCES Required: List two references in the space provided below one should be a person you serve under (for example, pastor, mini-church leader) and one should be a person you minister with (for example, mini-church member, small group participant) Person you serve Name: Phone Number: under: Person you minister Name: Phone Number: with: SIGNATURES Please sign: Printed Name:

Signature:

Parent or Guardian Name if under 18:

Parent or Guardian Signature: FOR USE BY THE ROCK OUTREACH, INC. OFFICE STAFF ONLY Date: Reason Declined: Initials: Approved: Declined: