Mt. Zion Baptist Association
Tuesday, September 07, 2010

Application for Short-Term Mission

 

PERSONAL INFORMATION

Date:                                       


Name:                                                                                                       
Address:                                                                                                   
City:                                                State:           Zip Code:                     

Telephone:  (      )             Work:  (       )                Cell:                           
Email:                                                                                                        

Date of Birth:                       Social Security Number:                            
Passport Number:                                                                                     
Date of Issue/Expiration Date:                                                                

          Male                    Female

Maital Status:
      Single            Married            Separated     
       Divorced         Engaged           Widowed

Spouse's Name:                                                                                      
Address:                                                                                                   
Telephone:                                                                                               
Email:                                                                                                       

In Case of Emergency, please notify:
Name:                                                            Relationship:                          
Address:                                                                                                        
City:                                                State:            Zip Code:                         
Telephone:                                       Work:                                                    
Email:                                                                                                             

FIELD

Name of Mission Project:                                                                            
Dates of Project:                                                                                           
Field Assignment(Country):                                                                         

Please describe the ministry you will have on the field:                             
                                                                                                                         
                                                                                                                         

Please indicate any special skills, talents or Christian service experience
that you feel may be helpful on the field:                                                         
                                                                                                                            
                                                                                                                            
                                                                                                                            

Please list missions experience:
Country                     Mission Organization             Dates                Ministry
                                                                                                                           
                                                                                                                           
                                                                                                                           

INVOLVEMENT

Church Membership (name of church):                                                           
How long have you been a member:                                                               

Please list the ministries with which you have been involved at your church:
Please include time of involvement and any leadersip positions held.
                                                                                                                             
                                                                                                                             
                                                                                                                              

Please list the ministries with which you have been involved outside of your
church include time of involvement and any leadership positions held:                                                                                                                          
                                                                                                                                    
                                                                                                                                    

MEDICAL INFORMATION

How would you describe your health?
       Excellent            Good         Average        Poor

Please state any major illness(es) you have had in the last five years:
                                                                                                                      
                                                                                                                      
                                                                                                                       

Are you presently under the care of a physician?      Yes              No
If yes, please explain:                                                                                  
                                                                                                                       
                                                                                                                       
                                                                                                                       

Please list any medications you are taking:                                              
                                                                                                                         
                                                                                                                        

Please list any allergies you have:                                                               
                                                                                                                          
                                                                                                                         

Personal Health Insurance Information:
Health Insurance Provider:                                                                            
ID #:                                                                                                                  
Group #:                                                                                                           
Name of Policy Holder:                                                                                  
Place of Employment:                                                                                    

Name of Beneficiary:                                                                                      
Relationship to You:                                                                                        

TESTIMONY

In the space provided below, please share your salvation testimony.  Please
include how long you have been a believer, how you were saved, and describe
your walk with the Lord at the present time:

 

 

 

 

 

 

Please explain briefly why you desire to go on this mission trip and what
you hope to see the Lord do in and through you.