Mount Pleasant Presbyterian Church (USA)

MISSION TRIP APPLICATION FORM

PERSONAL INFORMATION:

Full Name (as it appears on your passport)

Address

City  St  Zip

Country       Gender M   F

Home Phone 

Cell Phone

Email Address 

Professional Position and Interest

TRIP INFORMATION:

Name of TripAfricaHonduras - HabitatHonduras - LAMBHonduras - MedicalNicaragua Date of TripJune, 2009February 6-14, 2009July 10-17, 2009

Have you ever been on a mission tripYesNo   

Do you speak any foreign language Yes No

If yes, which one(s)

FAITH STATEMENT:

Why do you want to participate on this trip?

What are your concerns and expectations for this trip?

HEALTH INFORMATION:

General Health:Good  Fair  Poor

Allergies

In case of emergency, pleasey notify:

Name

RelationshipBrotherFriendFatherHusbandMotherNeighborOtherSisterWife  Phone

Name and phone number of overseas travel insurance

MPPC encourages you to consult your physician prior to any trip.

PASSPORT INFORMATION:

Date of Issue Expiration Date

 Place of Issue