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FAITH LANDMARKS MINISTRIES YAM MISSIONS TEAM APPLICATION

Mission trip applying for: YAM New York City Urban Impact Mission Trip Dates: June 16-June 22 Last Name:_________________________ First:_______________________ Middle:_________________________ Date of Birth: _______________________ Phone: House:______________________ Work:_______________________ Cell: ____________________________ Address: ________________________________________________________________________________________ Email: _____________________________________________ Frequency you check email: ____________________ Are you a member of FLM? _____________ o Approximate date of membership: ____________ If not a member of FLM, what church do you attend? ______ _______________________________ Do you attend at least one service a week? ___________ How do you plan to pay for the trip cost and expenses while traveling?

__________________________________________________________________________________________ __________________________________________________________________________________________
If you will be raising support, please include your plan:

__________________________________________________________________________________________ __________________________________________________________________________________________

As a part of this team, it is expected that each team member be physically fit, willing, and able to participate by possibly walking or hiking long distances, and standing for long periods. Are there any physical limitations we should be aware of in considering your application? __________________________________________________________________________________________ __________________________________________________________________________________________

All information provided in this application is true and complete. I understand that being a team member is a privilege and I must be approved to travel on this trip. I understand that no potential team member will be considered until the Hold Harmless agreement is signed.

Signature of participant: _____________________________________________ Date: _________________________

FAITH LANDMARKS MINISTRIES MISSIONS HOLD HARMLESS AND INDEMNIFICATION AGREEMENT


I understand and agree with the following terms and conditions pertaining to the FLM sponsored trip to: New York City, NY: June 16-22, 2013 By signing below, as the participant (or parent/guardian if participant is a minor) I understand that I will be participating in this mission trip at my own choosing and at my own risk. I thereby further agree to hold FLM harmless from any and all liability, claims, or losses that might arise out of any loss, alteration, or destruction of personal property which I have with me on this trip. This includes, but is not limited to: luggage, purses, bags, passport, money and jewelry. 1 I (or parent/guardian if participant is a minor) agree to hold FLM harmless from any liability, claims, or losses that might arise out of injury, sickness, disease, or death suffered by me during this trip. I agree to indemnify FLM and bear the responsibility and expense to cure or correct any injury, sickness, disease, or death that might be sustained during the trip. I will further indemnify and hold FLM harmless from any claim that might arise in connection with any injury or treatment of any injury to my person. 2 I (or parent/guardian if participant is a minor) further understand that I will indemnify and forever hold and save FLM harmless from any injury and/or death of another caused by me or connected with my conduct in any way. In other words, if my conduct causes injury and/or death of another, I will hold FLM harmless and indemnify FLM if any action is brought against FLM. This includes, but is not limited to, attorneys fee incurred by FLM as a result of my conduct regardless of my guilt. This also applies to personal property. Again, if my actions cause loss or damage to the personal property of another, I will hold FLM harmless and indemnify and forever save FLM from any action brought against FLM as a result of my conduct. 3 I (or parent/guardian if participant is a minor) understand that FLM does not have any insurance, including, but not limited to, insurance for health, workers compensation, disability, and/or life benefits that would cover me as related to my participation in this trip. I have my own insurance coverage (travel/ medical insurance is included in the cost of the trip) or will assume full responsibility for any health claim and further direct my family, successors, heirs, assignees, executors, and personal representative to assume full responsibility for any health and/or death claims. 4 Photographs, videos, etc. may be taken during this event. These could be used at later dates for website, event promotions, shown during services, etc. Do you approve of your childs image being photographed or videotaped during this event? Yes ____ No ____ Signature:___________________________________________________________________Date:_________________________
To be signed by participant (or parent/ guardian, if participant is a minor)

5. I the participant will obey the rules and regulations as stated below, which may be subject to change in order to manage the safety and wellbeing of all participants involved. FLM MISSIONS TRIP RULES & REGULATIONS 1. Be in agreement with the vision and purpose of this trip and be in full support of the effort. 2. Be willing to submit to leadership in charge. 3. Be willing to work as a team member with a spirit of love and cooperation. 4. NO strife, complaining, competition, or gossip. 5. Maintain a neat personal appearance. 6. Do not use this trip for personal business or ministry gain. 7. Any secular music found will be confiscated and not returned! 8. Consumption of drugs or alcohol of any type is not permitted. 9. Appropriate behavior w/the opposite sex (NO public (or private) displays of affection amongst any unmarried team members). 10. Failure to adhere to these rules may result in early dismissal from the trip at the expense of the individual/parent.

BY SIGNING BELOW THE PARTICIPANT (OR PARENT/GUARDIAN, IF PARTICIPANT IS A MINOR) ACKNOWLEDGES AND ACCEPTS THE ABOVE AGREEMENT To be completed by participant (or parent/ guardian, if participant is a minor)

Name (please print) ___________________________________________________________________________________ Address _____________________________________________________________________________________________ Parents/ Guardians ____________________________________________________________________________________ Home Phone _________________________ Work Phone _________________________ Other phone _________________ Name of emergency contact/ relationship: __________________________________________________________________ Home Phone _________________________ Work Phone ________________________ Other phone__________________ Is an FLM representative authorized to approve medical treatment? Yes____ No____ Date of last tetanus shot ___________ Please list any medical conditions, problems or concerns, allergies? _____________________________________________ Current medications being taken (for allergies etc) _________________________________________________________ _________________________________________________________________________________ Date: _____________ Signature of parent/guardian: ____________________________________________________ Date: __________________

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