North Way Christian Community

Mission Trip Registration

India Adult Mission Trip - Jan 2019


1/8/2019 - 1/18/2019
$2,700.00
$200.00

Additional Information

Please note, you must complete this form and submit with the required deposit. This form will not save to be completed at a later time. It could take approximately 30 minutes to complete and should be completed by the person applying for the team.  You will need the following: a credit card to pay the required deposit, your current health insurance information, the names and contact information for 2 character references. 
Name as it appears on your passport (International trips only-otherwise N/A):
*Date of Birth:
Mobile Phone Number if different than above:
*I attend North Way (select one):
If other, what church do you attend:
*Are you in a Small Group:
If yes, name of Small Group Leader:
*Provide a name as a reference from a North Way staff person or Pastor:
*Provide name, phone and email for two character references(other than relatives)and their relationship to you:
*Please list previous Mission/International Travel Experience (Location & Year):
*Please list previous and current volunteer organizations and locations:
*Please list current church volunteer areas:
*Please list previous service projects (location and year):
*Please list any relevant skills/expertise (construction, nursing, foreign language, etc.):
*Emergency Contact: Provide name, address, phone, and relationship:
*
What is the state of your present health?
*Physical and environmental conditions on this trip may be different than what you are used to. Please take your current health conditions into consideration when applying for this trip.
*List all health conditions you are currently experiencing:
*Allergies:
*Are you allergic to Penicillin:
*List all medications you are currently taking:
*List all medical conditions you have had in the past with approximate dates:
*List any dietary restrictions you have:
*Do you snore:
*Do you use tobacco:
*Do you drink alcohol:
*If yes to the above, please detail:
*
Please provide your current health insurance information (company, policy & group #s).
*International Medical Insurance is provided for all participants on international teams and is included in the cost of the trip.
*Have you been arrested for any reason or convicted of a crime? If yes please provide detail
*All Short Term Mission participants (18 and older) are required to complete and submit clearance certificates from PA State Police, PA Child Line and FBI Fingerprints or Affidavit. 
Please go to www.northway.org/clearance for more information.
*In a brief paragraph, please describe your faith journey as a disciple of Jesus Christ:
*Briefly explain why you want to go on this trip, what you hope to see the Lord do in and through you & any skills you have:
*

Statement of Beliefs and Values

:
*

Participant Verification and Release

:
*Agreement and Understanding: