January 2-8 - Dominican Republic Service Trip

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Full Name* This field is required.As it appears on your passport.
First Name
Middle Name
Last Name
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Preferred NameName as you would like to be called if different from above.
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Date of Birth* This field is required.
Date
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5
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6
Passport
Number
Expiration Date
7
Email* This field is required.
example@example.com
8
Phone Number* This field is required.
Area Code
Phone Number
9
What is Your T-Shirt Size? (Men's Sizing)* This field is required.This is for your Team T-shirt
X-Small
Small
Medium
Large
X-Large
XX-Large
10
What is your preferred method of communication?* This field is required.We ask you to check your email at least weekly for our communications.
Email
Text
Telephone
11
Relationship Status
Single
Married
Other
12
Emergency Contact #1* This field is required.An Individual in the USA not Traveling with You.
Name
Relationship
Complete Address Including State and Zip
Telephone
Email
13
Emergency Contact # 2* This field is required.An Individual in the USA not Traveling with You.
Name
Relationship
Complete Address Including State and Zip
Telephone
Email
14
Health Questions* This field is required.If you do not have Health Coverage, please enter "NONE"
Health Care Provider
Policy Number
Primary Physician
Physician's Phone
List any Allergies (Food, Medicine, etc) OR respond "NONE".
Are You in Good Health? Respond either YES or List any Serious Health Issues
15
Do you have or have you ever been under a doctor's care for heart problems, diabetes, depression, breathing problems, difficulty in walking, back problems or any other serious illness? If "Yes" explain. If "No" mark "No"* This field is required.Please describe or indicate "no".
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16
Please list any food allergies, psychological challenges, addictions, medical issues or medications and instructions you want us to be aware of. (Respond "No" if none.)
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Please tell us why you would like to join this trip?* This field is required.
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Have you ever been on a Service Trip? If yes, where and when.?(If No mark "No".).* This field is required.If no, please enter N/A.
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Do you have a background in Missions or Service? * This field is required.None is Required
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Do you speak languages other than English, if yes please list them and tell us how fluent you are. (Please write "No" if English only.)* This field is required.
21
Skills* This field is required.Please check all that apply.
Dental
Medical
Nursing Medical
Music Talent
Sing
Guitar
Drums
Keyboard
Elderly
Children
Special Needs
Face Paint
Photography
Video
Social Media
Organize
Fundraise
Teaching
Computer Skills
None of the Above
22
More Skills* This field is required.Please check all that apply.
Carpentry
Electrical
Masonry
Plumbing
Agricultural
Roofing
Heavy Equipment Operator
Construction
Painting
None of the Listed Skills
23
Skills, Experience, and or TalentsDid we miss anything?
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Spiritual BackgroundBrief remarks.
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Are you willing to engage in the whole trip as a team member approaching new situations openly, honestly, and respectfully? * This field is required.
YesNo
26
What interests you the most about this trip?* This field is required.
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How did you hear about the trip?* This field is required.
Friend
Flyer
Social Media
Work
School
Other
28
Name of Friend or Referral* This field is required.From "How did you hear about us?"
29
Do you authorize a $250 Non-Refundable Application Fee?* This field is required.Any applicant who is declined will be refunded.
YESNO
30
My $250.00 Non-Refundable Application Fee.* This field is required.
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ORDER SUMMARY
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My $250.00 Non-Refundable Application Fee.
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