Missions Application

Applicant Information – Step 1 of 4

Name *

First

Last

Address *

Address Line 1

City

State

Zip Code

Phone *

Email *

DOB *

Passport # *

Passport Date of Issue *

Passport Date of Expiration *

Social Security #

This is for background check purposes. If your church or organization is running a background check you do not need to enter this information.

Trip Description *

Mission Trip
Pastor Conference
Exploratory Trip

Team Leader

If coming with a team.

Trip Start Date

Trip End Date

If unsure of exact dates enter the first of the month you plan to travel.

Church Affiliation

Reference #1 Name *

This should be a church pastor, church leader, ministry leader or discipleship leader.

Reference #1 Phone *

Reference #1 Email

Reference #2 Name *

This should be a church leader, co-worker or friend.

Reference #2 Phone *

Reference #2 Email

Describe why you want to participate in a mission trip to Haiti.

Doctor Name

Doctor Phone

Describe any health issues, allergies or physical limitations

Are you currently taking any medications? *

If yes, please list medications and possible side affects

Healthy insurance company *

Policy Number *

Group Number

Emergency Contact *

Relation

Emergency Contact Phone *

Emergency Contact email

I understand the following: *

Participating in this mission trip is elective and I could encounter health or safety risks as a result of electing to participate. I am at liberty to change my mind about participating at any time before departure.
It is my responsibility to assess all of the risks associated with traveling and participating in this mission trip. I affirm that I have completed that assessment and have decided to participate in this mission trip.
It is my responsibility to maintain knowledge of travel advisories, medical advisories or other risks until departure and while I am on location.
It is my responsibility to notify the mission trip leadership if I learn of anything that would alter the risks to me or others at any time.
The mission trip leadership and participants may not be able to intervene or rescue me if I become involved in acts of crime or violence.
Medical care might not be readily available, and medical facilities probably will not meet the standards typical of the United States.
To the best of my knowledge, my health is sufficient to participate in this trip. If I have health questions related to this mission trip or my participation in it, I will consult my physician.

Please check each box to confirm your agreement of each statement.

Image and Video Release

GVCM intends to use these images and videos in newsletters, web pages, videos and other publications for the purpose of sharing and promoting its ministry activities.
Your fellow team members may intend to use these images personally, or with another church or organization, and they may also intend to use them for similar promotion purposes.
In some cases, you will pose or otherwise knowingly participate in the creation of these images and videos, but at other times, they may be taken without your knowledge.
GVCM may also receive images or videotapes taken by you during your mission trip, or of people and events before or after the trip.

During your mission trip, GVCM personnel, your fellow team members and others may take photographs or video of mission activities which you may be a part of. GVCM would appreciate your permission to use these images and videos to promote its ministry activities. Please check each box to give permission for use of photos and videos that include yourself.

Team Covenant

Please check each box to confirm your agreement of each statement.

As a member of this team, I agree to: *

Remember that I am a guest in this country working with Christ and the local church to strengthen and witness to the people of Haiti. My actions affect the witness of our team, the church, and the pastors in the community while I am on the field and after I am gone.
I will work as if I am working for the Lord. I will work hard and do my fair share of the work. (Colossians 3:23-24)
I will follow the leadership of my team leader, and missionaries even if things are not done the way I think they should be done. I will listen, work with the team and learn from the nationals on the field even if they do things differently than I would in the U.S. I am here to encourage and help my team accomplish its purpose. Any contact with nationals after the trip must be conducted under the full knowledge and authority of GVCM. (Ephesians 5:21)
I will abstain from the use of alcohol, tobacco, illegal drugs and any clothing, language or behavior that will negatively affect our witness for Christ.
I will make an effort to be part of the team. I will participate in preparation meetings, devotions and follow-up meetings. (Romans 12:4-5)
I will respect the expression of faith of our evangelical hosts and the work that is going on in the field. I will treat the nationals with respect. I am learning how God is working in another culture (1 Peter 2:17)
I am here to serve with Christ and put the needs of others before my own. I will do whatever it takes to get the job done and communicate the love of Christ. (John 13:4-17)

Disclaimer *

I certify that my answers are true and complete to the best of my knowledge.
I authorize GVCM and my fellow team members full rights to use or incorporate any photos and video, in whole or in part, for an indefinite period of time, for any purpose and in any media or format they deem appropriate, including, but not limited to, public relations, advertising and general publicity.
I hereby assume all risks of personal injury, sickness, death, damage and expense as a result of the participant’s involvement in this mission trip, and any recreation or work activities it involves. I release, hold harmless, and indemnify GVCM, it’s directors, officers, employees, sponsors and/or agents for any and all claims and costs due to the liability, injury or damage which might occur to the participant as a result of involvement in this mission trip, whether willful, intentional or negligent. Furthermore, I agree to allow the mission trip leadership to release personal information about the participant to the U.S. State Department or other governments or agencies if they believe it would be in my best interest.
I give my authority and consent to GVCM to seek a doctor or qualified person to provide emergency medical treatment to the above named participant in the event of illness or injury while participating or traveling to/from any mission trip activity. I release, acquit, discharge and covenant to hold harmless GVCM, it’s directors, officers, employees, sponsors and/or agents from any and all actions, causes of actions, damages and/or liabilities arising from the medical treatment incurred during this activity.

Please check each box to confirm your agreement with each statement.

Date of Application Signature *

Parent Name if Applicant is under 18

First

Last

Parent Phone if Applicant is under 18

Team Covenant

Much of the world is watching as gang violence in Port-au-Prince & surrounding areas escalates to extreme levels. Experts believe that this crisis will be more devastating than the 2010 earthquake.

To help our team respond to the need during this time, go to gvcm.org/donate and give under the “where most needed” category.