CLARKSTON, GA MISSION TRIP APPLICATION FORM

APPLICATION AGREEMENT *

"I AGREE TO SERVE UNDER THE LEADERSHIP OF WORLD HARVEST CHURCH MISSIONS MINISTRIES. I UNDERSTAND THAT SHOULD I CHANGE MY PLANS ALL FEES PAID ARE NON-REFUNDABLE. ADDITIONALLY, ANY EXPENSE THAT HAVE OCCURRED OR WILL OCCUR THAT CANNOT BE REFUNDED OR AVOIDED MUST BE PAID BY PARTICIPANT. A BACKGROUND CHECK IS REQUIRED FOR THIS TRIP SINCE YOU WILL BE SERVING WITH CHILDREN.

TRIP INFORMATION

Select Clarkston, GA 2021 mission trip(s) you wish to participate in: *

Clarkston, GA | June 12 | $20 | Andre V.R.
Clarkston, GA | Aug 7 | $20 | Andre V.R.
Clarkston, GA | Oct 2 | $20 | Andre V.R.
Clarkston, GA | Dec 11 | $20 | Andre V.R.

Have you completed an application for Clarkston before? *

Yes
No

PERSONAL INFORMATION

Please complete all fields to the best of your knowledge before submitting your application.

Name *

First

Last

Email: *

Cell Phone # *

Other Phone #

Address

Address Line 1

Address Line 2

City

State

Zip Code

T-Shirt Size (Clarkston, GA Mission Trips not qualified for t-shirts; cost is $10.00 per shirt.) *

Date of Birth *

Enter: mm/dd/yyyy

If you are under the age of 18 please check below.

Under 18

What will your age be at the time of your trip? *

Do you have one or any of the following (check all that apply): *

CDL (Commercial Driver's License)
Driver's License
Learner's Permit
N/A

Are you willing to drive the StreetReach truck or Shuttle? (24 passenger shuttle requires CDL) *

StreetReach Truck
24 Passenger Shuttle (I have a CDL)
14 Passenger Shuttle (Does NOT require CDL)
N/A

Marital Status *

Single
Married
Divorced
Widower

Gender: *

Male
Female

Emergency Contact First and Last Name *

Emergency Phone # *

Emergency contact relationship *

Are you a member of WHC? *

Yes
No
Membership in progress

Is this your first mission trip? *

Yes
No

List the countries or cities you have been to for missions:

What talents, skills, or previous experiences can you bring to this mission trip? *

What are your spiritual gifts? (Word of Wisdom, Word of Knowledge, Faith, Gifts of Healings, Miracles, Prophecy Distinguishing between Spirits, Tongues, Interpretation of Tongues) *

Do you serve at WHC? *

Yes
No

The position/department you serve at WHC

Health Information

NAME OF HEALTH INSURANCE PROVIDER

Health Ins Policy #

Doctor's Name

Doctor's Phone #

Do you have any allergies to food, medication, etc.? *

Yes
No

List of any allergies: Medication, foods, other. *

Do you have any medically mandated diet restrictions? *

Yes
No

List all medically mandated diet restrictions:

Do you have the following? *

Do you have any chronic or ongoing health conditions other than those mentioned above? *

Yes
No

List any chronic or ongoing health conditions:

Are you currently taking any prescription medication? *

Yes
No

List any prescription medication you are currently taking:

How would you describe your overall health?

Vaccinations: *Based on the location of your mission trip some vaccinations are REQUIRED. Please refer to the Get Ready - Trip Preparation tab for more info or check with your trip leader. *

I have contacted my personal physician or the Department of Public Health (404-657-2700) and have received the REQUIRED shots needed to go on this mission trip.
None yet other than vaccines recommended for the United States.

List any shots received:

Additional Comments:

AGREEMENT INFORMATION

AGREE: TYPE IN YOUR NAME *

First

Last

Signature *

Sign your name using a mouse

Mission Trip Personal Waiver /Release Statement *

I understand that this is a mission trip focused on sharing the Gospel of Jesus Christ. I release World Harvest Church and the World Harvest Church Missions Ministry from personal responsibility for accidents, sickness, or injury during the course of, or as a result of the trip. I also release World Harvest Church and the World Harvest Church Missions Ministry from responsibility for any lost or stolen possessions that might occur during the trip. As determined by World Harvest Church, I agree to submit to a background check in the event that I will be working with children. I will abide by the authority and decisions made by the World Harvest Church and the World Harvest Church Missions Ministry.

Seed For the Nations Deposit Information *

Review your application before you hit Submit. After you submit your application form you will be directed to the payment site where you can make a deposit, however YOU ARE NOT REQUIRED TO MAKE A DEPOSIT at this time. To deposit money into your personal SFN account for your trip, select "Seed For the Nations: Self/Dependent" from the drop down "Giving Type". For funds to be applied directly to your personal SFN account you must type your name in the WHICH FAMILY MEMBER IS THIS FOR? field.