Short Term Mission Trip Individual Application

Outreach/Program Applying for

Personal Information

Legal Name*

First Last

Nickname/Preferred Name (Optional)

Sex*

Male
Female

Date of Birth*

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone

Additional Phone*

Best Time To Call:

Time and Day of the Week

Are you currently a student?

Yes
No

If yes, what year?

If other, please specify

T-Shirt Size

Email*

Are You Under 18 Years Old?

Yes
No

Parent/Guardian Full Legal Name

First Last

Parent/Guardian's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian Cell Phone

Parent/Guardian Other Phone

Do you have a passport?*

Yes
No

You will need a passport for our international mission trips.

Marital Status

List full name, age, schooling grade level and gender of any children accompanying you

Name	Age	Grade	Gender

YWAM/Mission Experience

Have you ever been involved in a mission trip, missions training program, or any YWAM function?*

Yes
No

What mission trip or program?*

Leader's Name

Which ministry or YWAM center did you work with?

Date attended

Have you been involved in any other YWAM functions?

Church Information

Home Church*

Church Denomination

Church Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How long have you attended?*

Church Phone*

Church Website

Health

If necessary, are you able to walk 3-4 miles per day?

Yes
No

Are your Hepatitis A and Tetanus shots up to date?

Yes
No

Health Insurance Provider

Insurance Policy Number

Do you have any known allergies?

Yes
No

Please List Allergies:

Do you have any other health issues, medical conditions, or physical handicaps, or are you currently under a doctor’s care for any condition?

Yes
No

If yes, please describe:

Are you taking any medication at this time?

Yes
No

If yes, please specify:

Do you have a history of emotional instability or psychiatric treatment?

Yes
No

If yes, please describe:

Please list any special circumstances or situations we should know about

Emergency Contact

Name(s)

Relationship to Participant

Phone Number

Additional Phone Number

Agreement

I certify that all information in the application is complete and accurate. If accepted by Youth With A Mission, I will abide by the spirit, rules, and schedule of the program. I understand that my file are YWAM property, and I relinquish the right to view them or obtain information from them in any way.

Type full name to certify your agreement*

Today's Date*

Parent/Guardian type full name to certify their agreement (if applicant under 18)*

Today's Date*