Healing Place Church

Missions Application

Mission Trip Date: July 10-16, 2011 (Travel dates: July 9th & July 16th)

Servolution Informational Meeting: Saturday - June 4th – 9 a.m. – BridgeWay Ministry Center

General Information

Name: _______________________________________ I am: __Male __ Female

Address: ________________________________________________________

City, State, Zip: ____________________________________________________

Birthday: _____Month ______Day _______Year________

Are you under the age of 18? ___Yes ___No

Are you married? ___Yes ___No

Will your spouse be coming as well? ___Yes ___No

Team Information

Please specify any special skills / ministries that you are gifted in:
(i.e. electrical, painting, carpentry, drama, dance, face painting, balloon sculpturing, clowning, etc.)

Do you require special assistance? If so, please explain:

Can you bring any donated supplies? ___ Yes or ___No

(Suggested supplies: sample sized toiletries, disposable gloves, trash bags, paint brushes, etc.)

If so, please give details below.

Legal Information

Have you ever had a civil or criminal claim against you alleging physical or sexual abuse or sexual
harassment? ___ Yes ___ No

Have you ever been charged, arrested or convicted of a felony or misdemeanor? ___ Yes ___No

Have you ever been terminated from employment or had employment terminated, or has your employer ever
reprimanded you for reasons relating to allegations of physical or sexual abuse or sexual harassment? ___
Yes ___ No

Have you ever been reprimanded as a student for harassment (sexual or otherwise) or other inappropriate
behavior with another individual? ___ Yes ___ No

If you have answered yes to any of the above, please explain

below._________________________________________________________________________________
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Missions Information

Have you ever been on a mission’s trip before? ___ Yes ___ No
If so, where and when?
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Please explain why you want to attend this mission’s trip.

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Financial Information: (Please attach a $ 50. deposit with your application).

Trip Cost: $ 280 (Includes meals & seven nights of lodging – Meals for travel days are at your own expense)
Transportation Cost: $ 150. (Renting 2 – 15 passenger vans & gas)
T- Shirts: $ 10 each (you get one free but it must be worn every day).
Do you want to purchase additional T-Shirts? ___Yes ___No
T-Shirt Cost: # of Shirts x $10 = $ ____________
Total Cost for Trip: $___________

Will you need assistance in raising your funds? ___Yes ___No

Will you be willing to help in any fundraising efforts? ___Yes ___No

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Note: All funds are due by July 3, 2011. Make checks payable to: BridgeWay Community Church

MEDICAL AUTHORIZATION AND RELEASE OF LIABILITY

Please have each team member appropriately sign a

Medical Authorization and Release of Liability

My signature on this form confirms that I hereby release and hold harmless the Healing Place
Church (including its agents, employees, representatives, and staff -- collectively "HPC") from all liability for
any medical or health-related problem, personal injury or property damage that I may suffer or incur while
traveling or serving on a church-sponsored mission trip or ministry event.

For my own safety and well-being, I agree to abide by all rules and regulations established by the
HPC representative who is in a position of authority during this time of travel or service. I also accept
responsibility for my personal possessions and property during the time of travel or service.

If, during this time of travel or service, I am in need of medical or other health-related treatment, but
am unable to seek assistance for myself or make decisions for myself, then I give my permission, authority
and power of attorney to the HPC representative to seek appropriate care and treatment on my behalf.

I further agree that any claim for medical or health-related benefits, personal injury or property
damages will be limited to and asserted against insurance companies and/or third persons, parties or entities
other than HPC.

Name: ________________________________

Birthdate: _______________________

Home Telephone: ___________________

Work Telephone: ___________________

Cell Telephone: __________________________

Emergency Contact Information:_______________________________________________

Any known allergies: _______________________________________________________

Medications currently taking: ____________________________________________________

Date: ____________________________________

____________________________________
(Signature)

____________________________________
(Printed Name)

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(Parent Signature)
(Mandatory, if person traveling or serving is under age 18)