2009
SAMOAN MISSIONS INFORMATION
NAME:
_________________________________________________PHONE: _________________
E-MAIL
ADDRESS: ______________________________________ DOB ____________________
ADRESS:
________________________________________________________________________
________________________________________________________________________________
YOUR PROFESSION:
_____________________________________________________________
EMERGENCY
CONTACT WHILE ON TRIP:
NAME:_______________________________ RELATIONSHIP TO
YOU:___________________
PHONE
(home):_______________ PHONE(cell):_____________
PHONE(wk):_______________
ADDRESS:________________________________________________________________________
________________________________________________________________________________
ALL MEDICAL
CONDITIONS THAT YOU ARE UNDER DOCTORS CARE FOR:
________________________________________________________________________________
________________________________________________________________________________
MEDICATIONS CURRENTLY TAKING:
________________________________________________________________________________
________________________________________________________________________________
ALLERGIES:
_____________________________________________________________________
DO YOU AGREE
TO TREATMENT BY MEDICAL STAFF IF AN EMERGENCY ARISES?
________________________________________________________________________________
DATE OF LAST
TETANUS SHOT: __________________________________________________
IF YOU ARE AN MD,
PA, NP, RN, LPN, OR OTHER TYPE OF LICENSE MEDICAL PERSONNEL,
MUST ENCLOSE A COPY OF YOUR CURRENT LICENSE.
IF YOU HAVE
RECEIVED ANY MEDICAL TRAINING THAT COULD BE USED, MUST
SEND COPY OF CERTIFICATE RECEIVED.
CURRENT
PASSPORT NUMBER __________________, WE MUST HAVE A COPY OF YOUR PASSPORT
PLEASE NOTE THAT THIS INFORMATION WILL BE KEPT CONFIDENTIAL
UNLESS IT IS
NEEDED FOR MEDICAL ISSUES THAT ARISE ON THE TRIP.
IF YOU HAVE
ANY QUESTIONS, PLEASE CONTACT
Pastor Pele : (803) 269-6708
E-MAIL:
Mail this form
back to: Pastor Vaifanua
Pele,
or email it back.. Thanks!
Why are you interested in this short-term
ministry?
Is
this your first time on a mission trip?
_________ If no, when did you go? ____________
Where?
_______________________________________________________________________
What
kind of ministry do you expect to be doing on this trip?
_______________________________________________________________________________
How
has your experience prepared you for this trip?
________________________________________________________________________________
(if you need more space, please write on the back)
Please
write the major areas God has gifted you for ministry: ________________________
Ministering
overseas demands the adaptability to differences (e.g. language, ministry
methods, food, standards of house, privacy, etc). How has your experience
prepared you for coping with these differences?
________________________________________________________________________________
Personal
Reference:Please give this to any person who knows you well enough
to answer these questions. Ask them to
return the completed form to us at:
___________________________
has expressed an interest in being a part of the Mission Team for Samoa
Medical/Evangelism Mission 2008. We
would like your input as her/his family/friend.
Would you please fill out this form and return to the address listed
above? Thank you for your time.
2.
In what
church ministries or activities has this applicant been involved?
3. Please list
their area of strength or giftedness.
_______________________________
__________________________________________________________________________
4.
Please list
any concerns or areas where growth is needed.
___________________
5.
Please give your
overall reaction to his/her desire to minister cross-culturally.
_________________________________________________________________________
Additional comments:
________________________________________________________
_____________________________________________________________________________
(If you need more space, please write on
the back)
Your name:
______________________________________telephone___________________
Address: ____________________________________________________________________
Relationship to applicant:
____________________
Signature
_________________________________________ Date: ______________________
Please
fill out this form and return to: Mission of Hope Ministries, Samoa Medical
Mission 2008, Attn:
Pastor Vaifanua Pele,
_____________________________ has expressed an
interest in being a part of Samoa Medical/Evangelism Mission Team 2008. We believe the Great Commission was given to
the church. We believe your church
would be ministering through him/her in
1.
How long has
he/she been a part of your church?
________________________
2.
In what
church ministries or activities has this applicant been involved?
3.
Please list
the applicant’s area of strength or giftedness
4.
Please list
any concerns or areas where growth is needed
5.
Please give
your reaction to this person’s desire to minister cross-culturally.
Additional
comments: ________________________________________________________
(If
you need more space, please write on the back)
Please
print name _____________________________________Telephone________________
Church
name ___________________________________________________________________
Address
________________________________________________________________________
Signature_________________________________________ Date
________________________