APPLICATION for Feb 25- Mar3 2007 TRIP to GULFPORT

South Shore Baptist ChurchApplication to
Join the Short-Term Disaster Relief Team
Today’s Date:
Destination: Gulfport, MS — Feb. 25-Mar. 3, 2007
Last Name:
First Name:
Date of Birth:
Home Address:
e-mail Address: ____________________
Cell Phone: _______________________
Home Phone:
Work Phone:
Marital Status: _____Citizenship: _____ Passport No. N/A Single/Married/Widowed/Divorced
Have you received Christ as your Lord and Savior? Y/N
Your Church____________________________ Pastor____________________tel.____________
How are you involved? ____________________________________________________
Have you gone on a mission/service trip before? Y/N
Where?
For how long? With whom:
What did you do on that trip?
Describe briefly your previous experience:


What do you hope to accomplish on this trip?

Please check the following that apply to you:
 Can lead in a worship service Can lead in a Bible study Can deliver a sermon Can lecture on public health issues Can lecture on personal health issues Skilled aviation mechanics Skilled automotive mechanics Skilled carpenter Skilled electrician Am a medical doctor (specialty) Am a nurse practitioner Am a medical lab technician  Can sing a solo Can lead in group singing Can play a musical instrument (name) Can do a puppet show Can do a magic show Proficient in Accounting practice Proficient in Word Processing Skilled mason Skilled in HVAC Skilled plumber Am a registered nurse Am a practical nurse
Please describe any other skill/ability that may be an asset to this service trip:
Please describe your general health condition:
Please list any prescription medicine you are taking:
If you had any of the following, please give the date and describe briefly the results:
Angina:
Heart Attack or Heart Surgery:
Hepatitis:
HIV/AIDS:
Hypertension:
Stroke:
Your Blood Type: Are you Diabetic? Y/N
Do you have high Blood Pressure? Y/N
Please list any known allergies:
Please list any diet restrictions:
Other condition(s) that concerns you:
Name of your personal physician: Telephone No.
Name/Phone # of person to notify in case of Emergency:
Relationship: Telephone No
Are you able to finance this trip yourself? Yes/No
If not, what is the amount of financial assistance you are looking for?
Please describe any other concern/idea you may have regarding this mission trip:

I understand this is a church-based disaster relief service project. If chosen to participate I will act for the entire time in a manner that honors the name of Christ and of his churches. I acknowledge the decision of the Disaster Relief Task Force to be final. If accepted, I will attend all the orientation sessions and will cheerfully give up my privileges which I normally enjoy at home, and will do whatever is necessary to accommodate the people and situations I am placed in. Furthermore, I will abide by the decisions of the trip leader and and/or the on-site trip hosts.

Signed

Date

For use by the Disaster Relief Task Force:
Action:
Date