Mission Trip Application – Emmanuel Miami

Last Name *

First Name *

Address *

City *

State, ZIP *

Home Phone

Cell Phone *

Email Address *

Date of Birth *

Occupation / Profession

Do you have a valid passport? *

Passport Number (if yes)

Passport Expiration Date (if yes)

Nationality *

Do you have a valid Alien / Resident Card? *

Alien / Resident Card Number (if yes)

Alien Card Expiration Date (if yes)

Which Mission Trip are you applying for? *

Will you also participate in the Youth Camp (separate leg of the trip)? *

Yes, I will participate in Youth Camp No, mission trip only

Medical Conditions, Illnesses, or Disabilities

Current Medications

Dietary Restrictions *

If Other dietary restriction, please describe

Languages Spoken (check all that apply) *

Haitian Creole French Spanish English Other

Emergency Contact 1 — Full Name *

Emergency Contact 1 — Relationship *

Emergency Contact 1 — Phone *

Emergency Contact 2 — Full Name *

Emergency Contact 2 — Relationship *

Emergency Contact 2 — Phone *

Have you been on a mission trip before? *

Skills and Abilities (check all that apply)

Why do you want to go on this mission trip? *

Payment Plan Preference *

Full payment upfront Installments — I will arrange a payment plan with the Missions Department

I understand this trip requires fundraising and I am prepared to participate *

Is this application for a minor? *

No, I am 18 or older Yes, this is for a minor

Parent / Guardian Full Name (if minor)

Parent / Guardian Phone (if minor)

Relationship of Guardian to Minor

I commit to attending all required pre-trip training and orientation meetings *

Code of Conduct: I agree to conduct myself in a manner consistent with the values of Emmanuel Haitian Baptist Church for the full duration of this trip — including respecting leadership, abstaining from alcohol and inappropriate behavior, and representing the church honorably at all times *

Liability Waiver: I hereby release and agree to hold harmless Emmanuel Haitian Baptist Church and their affiliated ministries, their directors, pastors, and representatives, including volunteers, from any and all liabilities or claims for personal injury, illness, or death which may be incurred by me (or my child) during this mission trip and any associated activities *

Applicant Full Name (printed signature) *

Date Signed *

Parent / Guardian Full Name — Signature (if minor)

Date Signed by Parent / Guardian