Mission to Lirio Application

PARTICIPANT INFORMATION

First

Middle

Last

Address

Address Line 1

Address Line 2

City

State

Zip

Country

Home Phone

Mobile Phone

Country of Birth

Date of Birth

Mother's Name (for minors)

Mother's Phone

Father's Name (for minors)

Father's Phone

School Name

Grade

EMERGENCY AND HEALTH

First

Last

Emergency Phone 1

First

Last

Emergency Phone 2

Insurance Carrier

Policy# / ID#

Primary Physician

Physician Phone

Do you have any health concerns?

Dietary Restrictions

Do you have any known allergies?

Are there any medications we need to know about?

Are there any other considerations?

MISSIONS TRIP QUESTIONS

Tell us about any experience you have had on a short-term mission trip? Include locations, year, etc.

List any languages you speak other than English.

Why do you want to go on this mission trip?

Describe your relationship with Jesus Christ.

What will be your greatest contribution to the team?

What is one weakness that your team will be able to help you with?

Please list the name of a friend with whom you will talk to about the trip when you return.

PROVIDE 2 REFERENCES

Full Name

Phone

Full Name

Phone

PAYMENT INFORMATION

First

Last

Authorized Email (for receipt)