Mission To Lirio Online Application

Thank you for completing the online application for the 2024 outreach, currently scheduled for July 3-11, 2024 . Please complete the application to the fullest amount you can. If the participant is a minor, a parent MUST sign the application.

APPLICATION DEADLINE: February 12, 2024.

PARTICIPANT INFORMATION

Name *

First

Middle

Last

Please use name as it appears on your passport

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Mobile Phone

Email *

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

Emergency Contact 1 *

First

Last

Emergency Phone 1

Emergency Contact 2 *

First

Last

Emergency Phone 2

Insurance Carrier *

Policy# / ID# *

Primary Physician *

Physician Phone

Do you have any health concerns?

Dietary Restrictions *

If there are none, use N/A

Do you have any known allergies? *

If there are none, use N/A

Are there any medications we need to know about? *

If there are none, use N/A

Are there any other considerations?

If there are none, use N/A

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 *

Email *

Full Name *

Phone *

Email *

PAYMENT INFORMATION

Application Deposit

Price: $50.00

Authorized Purchaser *

First

Last

Authorized Email (for receipt) *