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Church Tsidkenu

Mission Trip Application Update

 

Today's Date: September 29, 2022

 

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Age *
Marital Status:*

Spouses Name

Passport # *

Date of Expiration *

Occupation and Employer:

Work Phone

Are you a student, if so what school do you attend?

Medical Insurance Information


Insurance Company *

Policy Number # *

Medical and Health History


Do you have any health conditions or disabilities that would prevent you from actively participating in this mission's trip? *

If yes please explain:

Primary Care Physician *

Phone# *

Name of Medication and Reason for taking Medication

Please list any and all Medical Conditions:

Ministry Information


What Church do you attend and for how long? *

(Pastors Name) *

Are you currently involved in ministry? If yes, give name of ministry & your ministry position. *
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*

Phone*
Second Participant's Date of Birth*
Second Participant's Information

Age *
Marital Status:*

Spouses Name

Passport # *

Date of Expiration *

Occupation and Employer:

Work Phone

Are you a student, if so what school do you attend?

Medical Insurance Information


Insurance Company *

Policy Number # *

Medical and Health History


Do you have any health conditions or disabilities that would prevent you from actively participating in this mission's trip? *

If yes please explain:

Primary Care Physician *

Phone# *

Name of Medication and Reason for taking Medication

Please list any and all Medical Conditions:

Ministry Information


What Church do you attend and for how long? *

(Pastors Name) *

Are you currently involved in ministry? If yes, give name of ministry & your ministry position. *
Third Participant's Name

First Name*

Last Name*

Phone*
Third Participant's Date of Birth*
Third Participant's Information

Age *
Marital Status:*

Spouses Name

Passport # *

Date of Expiration *

Occupation and Employer:

Work Phone

Are you a student, if so what school do you attend?

Medical Insurance Information


Insurance Company *

Policy Number # *

Medical and Health History


Do you have any health conditions or disabilities that would prevent you from actively participating in this mission's trip? *

If yes please explain:

Primary Care Physician *

Phone# *

Name of Medication and Reason for taking Medication

Please list any and all Medical Conditions:

Ministry Information


What Church do you attend and for how long? *

(Pastors Name) *

Are you currently involved in ministry? If yes, give name of ministry & your ministry position. *
Fourth Participant's Name

First Name*

Last Name*

Phone*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Age *
Marital Status:*

Spouses Name

Passport # *

Date of Expiration *

Occupation and Employer:

Work Phone

Are you a student, if so what school do you attend?

Medical Insurance Information


Insurance Company *

Policy Number # *

Medical and Health History


Do you have any health conditions or disabilities that would prevent you from actively participating in this mission's trip? *

If yes please explain:

Primary Care Physician *

Phone# *

Name of Medication and Reason for taking Medication

Please list any and all Medical Conditions:

Ministry Information


What Church do you attend and for how long? *

(Pastors Name) *

Are you currently involved in ministry? If yes, give name of ministry & your ministry position. *
Fifth Participant's Name

First Name*

Last Name*

Phone*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Age *
Marital Status:*

Spouses Name

Passport # *

Date of Expiration *

Occupation and Employer:

Work Phone

Are you a student, if so what school do you attend?

Medical Insurance Information


Insurance Company *

Policy Number # *

Medical and Health History


Do you have any health conditions or disabilities that would prevent you from actively participating in this mission's trip? *

If yes please explain:

Primary Care Physician *

Phone# *

Name of Medication and Reason for taking Medication

Please list any and all Medical Conditions:

Ministry Information


What Church do you attend and for how long? *

(Pastors Name) *

Are you currently involved in ministry? If yes, give name of ministry & your ministry position. *
Sixth Participant's Name

First Name*

Last Name*

Phone*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Age *
Marital Status:*

Spouses Name

Passport # *

Date of Expiration *

Occupation and Employer:

Work Phone

Are you a student, if so what school do you attend?

Medical Insurance Information


Insurance Company *

Policy Number # *

Medical and Health History


Do you have any health conditions or disabilities that would prevent you from actively participating in this mission's trip? *

If yes please explain:

Primary Care Physician *

Phone# *

Name of Medication and Reason for taking Medication

Please list any and all Medical Conditions:

Ministry Information


What Church do you attend and for how long? *

(Pastors Name) *

Are you currently involved in ministry? If yes, give name of ministry & your ministry position. *
Seventh Participant's Name

First Name*

Last Name*

Phone*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Age *
Marital Status:*

Spouses Name

Passport # *

Date of Expiration *

Occupation and Employer:

Work Phone

Are you a student, if so what school do you attend?

Medical Insurance Information


Insurance Company *

Policy Number # *

Medical and Health History


Do you have any health conditions or disabilities that would prevent you from actively participating in this mission's trip? *

If yes please explain:

Primary Care Physician *

Phone# *

Name of Medication and Reason for taking Medication

Please list any and all Medical Conditions:

Ministry Information


What Church do you attend and for how long? *

(Pastors Name) *

Are you currently involved in ministry? If yes, give name of ministry & your ministry position. *
Eighth Participant's Name

First Name*

Last Name*

Phone*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Age *
Marital Status:*

Spouses Name

Passport # *

Date of Expiration *

Occupation and Employer:

Work Phone

Are you a student, if so what school do you attend?

Medical Insurance Information


Insurance Company *

Policy Number # *

Medical and Health History


Do you have any health conditions or disabilities that would prevent you from actively participating in this mission's trip? *

If yes please explain:

Primary Care Physician *

Phone# *

Name of Medication and Reason for taking Medication

Please list any and all Medical Conditions:

Ministry Information


What Church do you attend and for how long? *

(Pastors Name) *

Are you currently involved in ministry? If yes, give name of ministry & your ministry position. *
Ninth Participant's Name

First Name*

Last Name*

Phone*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Age *
Marital Status:*

Spouses Name

Passport # *

Date of Expiration *

Occupation and Employer:

Work Phone

Are you a student, if so what school do you attend?

Medical Insurance Information


Insurance Company *

Policy Number # *

Medical and Health History


Do you have any health conditions or disabilities that would prevent you from actively participating in this mission's trip? *

If yes please explain:

Primary Care Physician *

Phone# *

Name of Medication and Reason for taking Medication

Please list any and all Medical Conditions:

Ministry Information


What Church do you attend and for how long? *

(Pastors Name) *

Are you currently involved in ministry? If yes, give name of ministry & your ministry position. *
Tenth Participant's Name

First Name*

Last Name*

Phone*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Age *
Marital Status:*

Spouses Name

Passport # *

Date of Expiration *

Occupation and Employer:

Work Phone

Are you a student, if so what school do you attend?

Medical Insurance Information


Insurance Company *

Policy Number # *

Medical and Health History


Do you have any health conditions or disabilities that would prevent you from actively participating in this mission's trip? *

If yes please explain:

Primary Care Physician *

Phone# *

Name of Medication and Reason for taking Medication

Please list any and all Medical Conditions:

Ministry Information


What Church do you attend and for how long? *

(Pastors Name) *

Are you currently involved in ministry? If yes, give name of ministry & your ministry position. *
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact Information

Full Name *

Address *

City, State, Zip *

Primary Phone *

Email Address *

Relationship *
Liability Waiver and Release Form:
By checking this box I, the undersigned, will be participating in a Short Term Mission Trip with Church Tisdkenu and the Fire Academy. I am voluntarily participating in this trip and all it's outings and I am aware of and recognize that there are risks involved in participating. I hereby assume all responsibility and all related risks of physical or emotional pain, suffering, illness, injury, damage, accident or death, including travel, associated with this trip. I knowingly and voluntarily enter into this waiver and release of liability and hereby waive any and all rights, claims, suits, or causes of action of any kind whatsoever arising out of my participation in this mission trip, and do hereby release and forever discharge Church Tsidkenu, the Fire Academy, their pastors, leaders, members, staff, volunteers, all affiliates, representatives, agents or attorneys for any physical or emotional pain, suffering, illness, injury, damage, accident or death, that I may suffer as a direct or indirect result of my participation in this trip, including travel. I acknowledge that I have carefully read this "Waiver and Release" Form and fully understand that it is a Release of Liability. I agree to voluntarily waive any right that I otherwise have to bring a legal action against Church Tsidkenu or the Fire Academy for all forms of personal injury or property damage. Today's Date: [date]
Tsidkenu Fire Mission Trip Agreement:
Do you agree to not drink, do drugs or participate in any illegal actives on this trip? Do you agree to not get in a relationship with anyone during this mission trip? Do you agree to walk in love towards everyone on your team? Do you agree to the best of your ability to bring the gospel, filled with signs, wonders, preaching, relationship and street evangelism on this trip? Do you agree to submit to Tsidkenu Church Leadership and Pastors on this trip? As someone applying for a Tsidkenu Mission trip, we want to let you know that we prayerfully consider each application, not everyone is suited for each mission trip, there are many considerations that go into each trip. Tsidkenu reserves the natural and spiritual right to deny any applicant based on their spiritual judgment. Do you agree to this process?
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Age *
Marital Status:*

Spouses Name

Passport # *

Date of Expiration *

Occupation and Employer:

Work Phone

Are you a student, if so what school do you attend?

Medical Insurance Information


Insurance Company *

Policy Number # *

Medical and Health History


Do you have any health conditions or disabilities that would prevent you from actively participating in this mission's trip? *

If yes please explain:

Primary Care Physician *

Phone# *

Name of Medication and Reason for taking Medication

Please list any and all Medical Conditions:

Ministry Information


What Church do you attend and for how long? *

(Pastors Name) *

Are you currently involved in ministry? If yes, give name of ministry & your ministry position. *
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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