Trip Information
Trip Location*
Trip Month/Year*
Basic Information
Name*
Birthdate* January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901
, AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Email*
Phone*( ) -
Yes
No
Emergency Contact
Primary Emergency Contact: Name*
Relationship*
Secondary Emergency Contact: Name*
Emergency Medical Information
Primary Care Doctor: Name *
Known Allergies/Current Medical Conditions/ Medications*
Agreements and Attachments
I understand that the training meetings for this mission project are critical for the spiritual unity and physical preparation of the entire team. I commit to faithfully attend all meetings at the scheduled times.*
I understand that all deposits are NON-REFUNDABLE, and once a plane ticket is purchased in my name, I am completely responsible for the payment of that ticket, regardless of any reason that would cause me to cancel my plans to go on this outreach. *
I have attached a copy of my DRIVERS LICENSE or other identification that will be used for travel (airline tickets, rental cars, emergency medical care )*
I have attached a copy of my MEDICAL INSURANCE CARD (front and back).*
International Trips Only - I have attached a color copy of my PASSPORT.
I have an up-to-date tetanus shot. (Required every 10 years)*
Sign *
Current Date* January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901
Confidential Health Questionnaire
Last Tetanus Shot * January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901
Blood Type *
Alcoholism
Anemia
Asthma
Bleeding Problems
Cancer
COPD
Diabetes
Drug Abuse
Heart Disease
High Blood Pressure
HIV Postive
Malaria
Peptic Ulcers
Psychiatric Illness
Seizures / Epilepsy
Stroke
Tuberculosis
Other
Other Listed Out
Please list any condition requiring special medical consideration (i.e. psychological/emotional disorders, limits in physical activity, major surgery in the past 3 years). Attach a separate piece of paper if necessary.*
Please list any dietary restrictions (due to doctor’s orders or food allergies).*
List any know allergies.*
List all medications you use. Provide information on dosage, frequency, and reason for taking all medication. Attach a separate form if needed.*
HBC Involvement and Mission Experience
If no, which church do you attend?
If you are not a member of HBC, please attach a Pastoral Recommendation.
List any Sunday School or Bible Study classes in which you participate.*
List any church and ministry related responsibilities you have held in the last three years. *
Have you participated in a mission trip? If so, when and where?*
Give a brief statement about how you were led to pursue this mission trip. *
Skills and Intrest Inventory
List and foreign languages you speak, if any.
List any skills, interests, or specialized training you have.*
Personal Relationship With Jesus
How and when did you become a Christian? *
Describe you current relationship with the Lord .*
Attachments
Attachment for Drivers License (Front) *
Attachment for Drivers License (Back)*
Attachment for Insurance Card (Front)*
Attachment for Insurance Card (Back)*
Attachment for Passport
Attachment for Special Medical Considerations
Only if needed.
Attachment for Medications
If needed
Attachment for Pastoral Recommendation (If not a member of Hillcrest)
