dogwood church mission team application...bible studies, and other activities consistent with the...

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Dogwood Church Mission TEAM APPLICATION

Which missions’ opportunity are you applying for? ___________________________

Personal Information 1. Name: __________________________________________________________________

2. Address: ________________________________________________________________

City: ________________________ State: _____________ Zip: _____________________

Phone Number: (____) ____-________ E-Mail __________________________________

3. Date of Birth: _______________

4. School: ___________________Grade: ________

5. Parents Name (under 18): ______________________ Email: ________________________

5. Emergency Contact: _______________________________ Phone: __________________

Skills 6. Language skills other than English: ___________________________________________ 7. Please list any Ministry Skills (including the arts): ________________________________________________________________________ 8. Have you been on a mission trip before? ______ Where? __________________________ ________________________________________________________________________ ________________________________________________________________________

With whom? ________________________________ When? ______________________ 9. Are you comfortable sharing the Gospel? ___yes ___no 10. Would you be willing to give a devotional or speak in a church service? ___yes ___no

Helpful Information

Official Name (as it would appear on a passport): ______________________________________ Marital Status: Single Married Engaged Widow/er Divorced Church Status: Member Non-member Baptized by immersion T-shirt size: S M L XL 2XL 3XL

Areas of Interest, Talent, or Experience: Mark any categories in which you would be willing to minister.

Witnessing Construction Musical Ministry Domestic Work Leadership Opps for Adults/College Age

Preaching Carpentry Song Leading Cooking Construction Foreman Personal Witnessing Masonry Soloist Laundry Kitchen Coordinator Teach in VBS or SS Electrician Group Specials Cleanup Team Devotions Coord. VBS Crafts Plumbing Piano(keyboard) Other Helps Director for VBS VBS Recreation Power Tools Guitar Photography Craft Director for VBS Drama or Puppets Misc. help as needed Other ___________ Video Medical Experience Speak Spanish Mechanic

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Please Supply The Following: 11. A written statement on why you want to go on this mission trip.

12. Please supply your personal testimony on a separate paper.

13. One personal reference stating personal Christian character and conduct from your Community Group Leader or other Dogwood member.

15. What community group are you a part of?

16. What missions’ opportunity are you interested in attending?

18. I agree with and will follow the policies for team behavior and attitude. _____ Yes _____ No Initial Initial

19. Once airline tickets are purchased, you will be responsible for the cost of those tickets even if you decide not to go. ______ (We will do our best to get refunds/transfers from the issuer, but we can not make any guarantees.)

Initial

Team members participating on Dogwood sponsored short-term mission trips are reminded they are ambassadors of Jesus Christ (II Cor. 5:20). As teams serve overseas, they not only represent Jesus, but also represent Christ- followers worldwide, Dogwood Church, our Pastor, the United States, the partnering mission agency and local Christian missionaries. This is a tremendous responsibility. For this reason, the Global Missions department asks that each team member seek to live above reproach in his/her actions and attitudes by agreeing to the following.

1. Team members must submit to the team leader’s authority.

2. Due to the political instability and anti-American sentiment in various countries around the world, Dogwood Church asks each member to refrain from expressing political opinions while overseas.

3. Team members chose to limit their freedom by abstaining from the use, consumption, or purchase of alcoholic beverages, tobacco or illegal drugs while on the trip.

4. Team members must adhere to the behavioral guidelines for each specific team set by the team leadership or partnering missions’ agency with a mind toward the culture to which the team is going. This will require a servant attitude toward all nationals and team members, as well as a willingness to learn from the lost culture. (I Cor. 9:19-23)

After consultation with the missions department, the team leader reserves the right to ask a problem team member to return home if that team member’s behavior is destructive to the team, the ministry, or the host community. Any additional cost incurred as a result of this action will be at the team member’s expense. ______ Initial

Initials______ Page 1 of 4

Dogwood Missions Ministry: PERMISSION/ WAIVER FORM

Name of Child or Adult Participant (please print) _________________________________ Address_________________________________________________________________ City____________________State__________Zip________Phone__________________ If the participant is a child, print the names of parent(s) and/or legal guardian(s) ________________________________________________________________________ Age of Child_________ Birth Date________________ Academic Grade____________ School__________________________________________________________________ Functions and Activities It is my understanding that participating in the programs and recreational and other activities of DOGWOOD CHURCH is a privilege. Prior to my participation in such activities, I acknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to activity-related accidents, physical injury due to transportation-related accidents, illness, or even death. In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware. Release of Liability By signing this Permission/Waiver Form, I expressly warrant that the child named above or I (if I am a participant) am capable of withstanding both the physical and mental demands of the activities discussed above. I also expressly assume all risks of the child or me participating in the activities, whether such risks are known or unknown to me at this time. I further release DOGWOOD CHURCH and its ministers, leaders, employees, volunteers, and agents from any claim that my child may have or that I may have against them as a result of injury or illness incurred during the course of participation in the activities. This release of liability shall include (without limitation) any claims of negligence or breach of warranty. This release of liability is also intended to cover all claims that members of the child’s or my family or estate, heirs, representatives, or assigns may have against DOGWOOD CHURCH or its ministers, leaders, employees, volunteers, or agents. I further agree to indemnify and hold harmless DOGWOOD CHURCH and its ministers, leaders, employees, volunteers, or agents from any and all claims arising from my participation in its activities and programs, or as a result of injury or illness of my child during such activities. Special Events and Field Trips I understand that the child named above, or I, will be participating in (special event activity) __________________ from (date) ______________until ________________. I understand that during this period my child/ward, or I, if I am an adult participant, may take part in activities such as: ___Transportation, various ministry activities, recreation, medical clinics construction, Bible studies, and other activities consistent with the purposes of the church.


First Aid and Emergency Medical Treatment I recognize that there may be occasions where the child named above, or I, if I am a participant, may be in need of first aid or emergency medical treatment as a result of an accident, illness, or other health condition or injury. I do hereby give permission for agents of DOGWOOD CHURCH to seek and secure any needed medical attention or treatment for the child name above, or me, if I am a participant, including hospitalization, if in the agent’s opinion such need arises. In doing so I agree to pay all fees and costs arising from this action to obtain medical treatment. I give permission for attending physician(s) and other medical personnel to administer any needed medical treatment, including surgery and, again, I agree to pay for the medical treatment. Publicity On occasion, DOGWOOD CHURCH takes photographs or makes an audio or videotape recording of children and/or adults involved in church activities. Such photographs or video records may be used by staff and participants to remember the activities and participants. In addition, such photographs and audio/visual recordings may be used in DOGWOOD CHURCH publications or advertising materials to let others know about our ministry. In addition, local news organizations may hear of our activities or events, and our church may invite or allow them to photograph or record our events for news reporting on special interest features. I consent to the use of any such audio or visual record of the child named above, or me, if I am participating, to be used, distributed, or displayed as agents of the church see fit. This consent includes but is not limited to: photographs, videotape, and audio recordings. Furthermore, I give permission for the child to be interviewed by the news media, or for such photographs and other audio or visual records to be used by the news media. Medical History Special medical needs or concerns (allergies, conditions, dietary needs, medications, etc.): ________________________________________________________________________ Health Insurance Health insurance information: Insurance Company_________________________________ Policy Number____________________________ Phone Number___________________ Group Number____________________________ Medical Doctor___________________________ Phone Number__________________


Emergency Contacts Name of persons and telephone numbers to call in case of emergency: Parent/Guardian__________________________Home_____________Work__________ Parent/Guardian__________________________Home_____________Work__________ Other__________________________________Home_____________Work___________ Swimming Ability ______Non-swimmer ______Beginner (capable of swimming for several minutes in deep water) ______Moderate (capable of swimming several lengths of pool) ______Advanced (capable of swimming long distances) Other Information Other information leaders should know about the child or adult participant: ________________________________________________________________________ ________________________________________________________________________ ************************************************************************ FOR USE ONLY IF THE PARTICIPANT IS A MINOR I represent that I am the parent/guardian of ______________________________________, who is under 18 years of age. I have read the above Permission/Waiver Form and am fully familiar with the contents thereof. I give permission for the child named above to participate in the activities of DOGWOOD CHURCH, including any special events/activities described above. In consideration for allowing the participation of the child in the activities of DOGWOOD CHURCH I hereby consent to the Permission/Waiver Form, including the Release of Liability above, on behalf of the child and agree that this Permission/Waiver Form shall be binding upon me, my family, heirs, legal representatives, successors, and assigns. Should it be necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, we (I) herby assume all transportation costs. __________________________________________ ___________________________ Signature of Parent or Legal Guardian Date __________________________________________ Print Name of Parent or Legal Guardian __________________________________________ ___________________________ Witness Signature Date


Adult Volunteers and Employees As an adult volunteer or church employee, I hereby agree to each of the consents and waivers listed above, including the Release of Liability, as pertaining to my own participation in functions, activities, special events, and field trips. __________________________________________ ___________________________ Signature Date Young Person’s Agreement I agree to participate in the functions and activities of church name, to cooperate with the leaders and other young people, and to conduct myself as a Christian. I promise to respect God, respect myself, respect other persons, and respect property. I understand that my continued participation in church activities depends on my support of this agreement. __________________________________________ ___________________________ Signature Date

Macintosh HD:Users:carmenbowra:Documents:External Ministries:FORMS:HEALTH FORM1.doc Page1 of 2

DOGWOOD CHURCH MISSIONS Health form (Confidential)

Please print in ink or type. Couples should fill out separate forms. ________________________________________ Name: _____________________________________ Age: ___________Date: _______________ Current Marital Status: � Single � Married � Divorced � Widowed ________________________________________ Heredity: Among your immediate family, grandparents, uncles or aunts, is there any history of cancer, tuberculosis, epilepsy, alcoholism, mental disorder, migraine headaches, asthma, diabetes, heart or any circulatory or blood disease? Specify relative and disease: __________________________________________________________________________________ Condition of health: � Poor � Fair � Good � Excellent Height: _____________ Weight: _____________ Immunizations: To your knowledge, which of the following have you had the normal immunizations for?

� Mumps � Rubella � Pertussis � Cholera � Tetanus � Typhoid � Measles � Hepatitis A � Hepatitis B � Diphtheria � Polio � Others: ___________________________

Allergies: Specify if you have any allergies (to medications, food, or other): __________________________ ____________________________________________________________________________________________________________________________________________________________________ Physical Conditions: Indicate whether you have or have had: (Also circle those that still apply to you now.) � Asthma � High Blood Pressure � Chronic Fatigue � Obsessive Thoughts � Respiratory Disorders � Diabetes � Endometriosis � Compulsive Actions � Epilepsy � Mitral Valve Prolapse � Pre-Menstrual Syndrome � Depression � Fainting Spells � Cardiac Problems � Sexually Transmitted Diseases � Anxiety Problems � Convulsions � Stomach Ulcers � AIDS Virus � Bipolar Disorder � Tic Problems � Rheumatic Fever � Anorexia Nervosa � Night Terrors � Leukemia � Tuberculosis � Bulimia Nervosa � Psychiatric Consult. � Cancer � Lupus � Speech Problems � Substance Abuse � Hepatitis � Thyroid Problems � Learning Disabilities � Alcoholism � Hypoglycemia � Back Problems � Sleep Difficulties � Drug Flashback � Anemia � Incapacitating Headaches �Att. Deficit/Hyperact. Disorder Females Only: � Irregular periods � Severe Cramps � Are you pregnant

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Medical History: Have you ever been turned down for medical reasons from any of the following? � Life Insurance � Military � Employment � College How many days have you been hospitalized in the past five years for the following: � Medical � Surgical � Psychiatric Explain: __________________

____________________________________________________________________________________ Temperament: Indicate which characteristics seem to apply to your temperament: � Impulsive � High-strung � Nervous � Calm � Easy-going � Introspective � Shy � Anxious � Moody � Self-conscious � Aggressive � Dominant � Optimistic � Cheerful � Enthusiastic � Irritable � Self-confidant � Often depressed Any lack of emotional control? � Yes � No Explain: _____________________________________ ___________________________________________________________________________________ Do you suffer from insomnia? � Yes � No Disturbed sleep? � Yes � No Explain: _____________________________________________________________________________ Have you ever seriously considered committing suicide? � Yes � No

If so, when?_________________ Stamina: Is there any reason why you cannot tolerate: � Rigorous outdoor activity? � High altitudes? � High temperatures? � Low temperatures? Explain: _____________________________________________________________________________ _____________________________________________________________________________ Do you have any handicaps which might hinder missionary service? Explain: ____________________________________________________________________________________ Are you on any type of special diet? Explain: _______________________________________________ _____________________________________________________________________________ Other:

We need to have information from your physician regarding any significant medical and/or emotional problems that currently affect you.

I certify that I have answered the above questions fully and honestly and that I have no other significant health problems. Signed: ____________________________________________Date: ______________________

AFFIDAVIT FOR TRAVELING WITH ADULT OTHER THAN PARENT

TO WHOM IT MAY CONCERN: I, ______________________________, GIVE PERMISSION FOR MY SON\DAUGHTER, , WHO WAS BORN ON ________________ TO ACCOMPANY AND/OR AND/OR

AND/OR ON A TRIP OUT OF THE UNITED STATES TO

FROM THROUGH . THIS IS ALSO OUR PERMISSION FOR

MEDICAL ASSISTANCE TO BE ADMINISTERED SHOULD THEY BECOME ILL OR

INVOLVED IN AN ACCIDENT.

_____________________________ Father Date _____________________________ Mother Date _____________________________ Legal guardian Date ___________________________ ______________ NOTARY SEAL AND SIGNATURE DATE NOTE: BOTH SIGNATURES NEEDED OR DIVORCE DECREE STATING SOLE CUSTODY.