El Salvador Application

8/14/2019 El Salvador Application

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El Salvador

Senior High Mission Trip Application

July 16-24, 2010

For Students going into 9th-12th grades

$100 Non-refundable deposit due with application by March 14, 2010

Total Cost: $1300

Please type or print with ink.

Make sure you have all signatures.

Do you have a current passport? Yes _____ No _____

Legal Name as it appears on your Passport or Birth Certificate:

Last _________________________ First________________________ Middle___________

Home Address ______________________________________________________________

City, State, Zip ______________________________________________________________

Birth date ___/___/___ Age ____ Birth Place ____________ County __________State ___

Family Information

Parents Name ______________________________________________________________

Are both parents active in church? ____ Yes ____ No Explain _______________________

Phone numbers of Parent(s) applicant resides with:

Day Phone (___) _____________________ Evening Phone (___) _____________________

Reference Information

Pastor ____________________________ Church Name ____________________________

Address ___________________________________________________________________

City _______________________________________ State ________ Zip_______________

Phone (___) _________________________ How long attending? ____________________


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Education Information

1. What year of schooling are you in? _______________ What is your major? ___________

2. Special award and honors __________________________________________________

__________________________________________________________________________

3. Special skills, abilities, or musical talents _______________________________________

__________________________________________________________________________

Health Information

1. What type of health are you in? __ Excellent ___Good ___Fair ___Poor

Explain ____________________________________________________________________

2. Is there any history of emotional, mental or physical handicaps? ___Yes ___No

If YES explain _____________________________________________________________

3. Do you use alcohol, tobacco, or illegal drugs? ___Yes ___No

If YES explain _____________________________________________________________

Miscellaneous Information

1. Will you be willing and able to eat whatever food you are served? ___Yes ___No

If no, please explain your diet requirements _________________________________________________________________________________________________________________

2. What is your shirt size: (Please circle one) S M L XL XXL

Spiritual Information

1. Your spiritual experience:

A. Conversion? When and how ________________________________________________

__________________________________________________________________________

Water Baptism? ___Yes ___No If yes when and where? __________________________

__________________________________________________________________________

Infilling of the Holy Spirit? ___Yes ___No If yes when and where? __________________

__________________________________________________________________________


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B. Tell us about your present involvement in your church, how long attending, faithfulness to youth

activities, do you tithe, give to STL?

__________________________________________________________________________

__________________________________________________________________________

C. Tell us about your present spiritual walk. Where are you, where are you going, and your concern

for others?

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

D. How often do you read your Bible and pray during an average week?

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

E. What method of Bible Study are you now using?

__________________________________________________________________________

__________________________________________________________________________

2. Your experience in Christian work.

A. What have you done: When, where, and with whom have you worked.

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

B. List particular examples of leadership experience.

__________________________________________________________________________

__________________________________________________________________________

C. List anything else you feel we should know about you.

__________________________________________________________________________


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D. What other Mission/AIM trips have you participated in? Please list where and when:

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

3. What area of childrens ministry do you enjoy most?(puppets, singing, crafts, etc.)

__________________________________________________________________________

__________________________________________________________________________

4. In a paragraph list your reasons for wanting to participate in this outreach.

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Important Note:

If you are accepted and decide not to accompany the AIM team, IRS regulations state that the $50 or$100 deposit and any additional payments are NON REFUNDABLE, NON TRANSFERABLE. If after you

have been accepted, and you decline to attend or your conduct is unbecoming a Christian and you are

dismissed before any money has been forwarded to the trip destination, your balance will be used to

defer team costs. If after you have been accepted, and you decline to attend or your conduct is

unbecoming a Christian and you are dismissed, any money for the trip that has been forwarded by

Kfirst, including plane tickets purchased on your behalf, you are liable to pay the remaining balance in

full. By signing this application I am making a commitment to fulfill all financial responsibilities and to

be in attendance at all team preparation meetings and activities.

Parents Signature ___________________________________________ Date ___________

Participants Signature ________________________________________ Date ___________

Your El Salvador application + $100 deposit must be turned in by Sunday, March 14, 2010


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El Salvador Payment Plan

March 14th Application and $100 deposit due

Payments can be made anytime prior to the recommended date.

Payments are highly recommended to be paid the second Sunday of the following months:

April 11th $300

May 9th $300

June 13th $300

After June 13th you are responsible for the full cost of the trip whether you go or not. Airline tickets will

now be purchased.

July 11th Final Payment $300_____

Total trip cost $1,300

Important Notes:

In fairness to others on the team, NO ONE will be allowed to go on the trip if they are not PAID-IN-FULL

when the trip departs. No money will be refunded. No exceptions.

Fundraisers may be available, however, REAL Student Ministries is NOT responsible for raising your tripfunds.

By signing below, I/we recognized the financial importance of this trip.

X ________________________________________________________ ____________Student Signature Date

X ________________________________________________________ ____________Parent Signature Date


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El Salvador Payment Plan

March 14th Application and $100 deposit due

Payments can be made anytime prior to the recommended date.

Payments are highly recommended to be paid the second Sunday of the following months:

April 11th $300

May 9th $300

June 13th $300

After June 13th you are responsible for the full cost of the trip whether you go or not. Airline tickets will

now be purchased.

July 11th Final Payment $300_____

Total trip cost $1,300

Important Notes:

In fairness to others on the team, NO ONE will be allowed to go on the trip if they are not PAID-IN-FULL

when the trip departs. No money will be refunded. No exceptions.

Fundraisers may be available, however, REAL Student Ministries is NOT responsible for raising your tripfunds.

Please Keep For Your Records


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Assumption of Risk(For those 18 years and older)

I, _________________________________________________ (name of volunteer), in consideration

of my acceptance as a short-term volunteer with Ambassadors in Mission (AIM) of National Youth

Ministries of the General Council of the Assemblies of God, represent and agree that:

1. I am a volunteer worker and acknowledge that I am not an employee of AIM, National Youth

Ministries of the Assemblies of God or the General Council of the Assemblies of God.

2. I am aware of the hazards and risks to my person and property associated with serving in a

missions capacity, such hazards and risks including, but not limited to, death or injury by accident,

disease, weather conditions, inadequate medical services and supplies, criminal activity, and

random acts of violence. I accept my assignment with full awareness of these risks, and, subject to

the insurance coverages described below, I voluntarily assume all risks of death, injury, illness, and

damage to myself or any member of my family associated with such risks, and any damage to my

personal property. I further recognize such risks have always been associated with missionary

service.3. I attest and certify that I have no medical conditions that would prevent me from performing my

duties.

4. Subject to insurance coverages described below, I waive and release any and all claims for

damages which I, or my heirs or successors, may have against AIM, National Youth Ministries of the

Assemblies of God, the General Council of the Assemblies of God, any District Council of the

Assemblies of God, the local church sponsoring the AIM trip, or any agent or employee of any of

such organizations, arising from my death, injury, or illness, or any property damage or loss

occurring during the term of my assignment or as a result of my assignment.

5. In the event that I have minor children who will accompany me on my assignment, I, acting both

on my own behalf and in their behalf as their parent and legal guardian, and subject to the

insurance coverages described below, do hereby assume all risks of death, illness, or injury thatthey may suffer as a result of said assignment, from those causes described above.

6. I expressly waive any defense to the enforcement of any provision of this commitment arising

from a claim of lack of consideration and warrant that this commitment constitutes a legal valid,

and binding obligation upon me enforceable against me in accordance with its terms.

7. I expressly agree that this assumption of risk and indemnity agreement is intended to be as broad

and inclusive as permitted by law. I further state that I have carefully read the foregoing

assumption of risk and understand its contents, and I voluntarily sign this release of my own, free

act.

initial __________ date ____________


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Parental Consent Forms(for those under the age of 18)

Parents and legal guardians of minor children must complete this form and return it to your trip leader.

The information requested is designed to assist the church in providing for the safety of minors during

church-sponsored activities.

Childs name ________________________________________________________________________

Fathers name _______________________________________________________________________

Mothers name _______________________________________________________________________

Childs address _______________________________________________________________________

City _________________________________________________ State __________ Zip ____________

Phone ____ ________________________________Mobile: __________________________________

Work phone______________________________________Email:______________________________

Medical Questionnaire

1. Is your child presently being treated for an injury or sickness or taking any form of medication for any

reason? _ Yes _ No If yes, explain and list any medications.

_____________________________________________________________________________________

___________________________________________________________________________________

2. Is your child allergic to any type of medication? _ Yes _ No If yes, explain.

_____________________________________________________________________________

_____________________________________________________________________________

3. Does your child medically require a special diet? _ Yes _ No If yes, explain.

_____________________________________________________________________________

_____________________________________________________________________________

4. Does your child have (or has ever had) any of the following: (check all that apply and explain below)

_ Seizures _ Asthma _ Heart murmur _ Diabetes _ Hay Fever _ Kidney disease

_ Other ______________________________

Explain

_____________________________________________________________________________________

_________________________________________________________________

5. Does your child have any allergies? _ Yes _ No If yes, explain and list medications.

__________________________________________________________________________________________________________________________________________________________

6. Has your child ever sleep walked? _ Yes _ No

7. Can your child swim? _ Yes _ No


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Parental Consent Forms(continued)

Medical Questionnaire

8. Does your child have any physical condition or illness which would prevent him/her from participating

in normal, rigorous activity? _ Yes _ No If yes, explain.

____________________________________________________________________________________

initial __________ date ____________

Medical Treatment Authorization

We understand that we will be notified in the case of a medical emergency involving our child. However,

in the event that we, or either of us, cannot be reached, we authorize the calling of a doctor and the

providing of necessary medical services in the event our child is injured or becomes ill. We authorize any

adult leader participating on this trip or any Assemblies of God missionary to make emergency medical

care decisions on behalf of our child, if required by law or a health care provider. We understand that

the national AIM office, or any of their agents, employees, or volunteers, will not be responsible for

medical expenses incurred on the basis of this authorization.

We agree to notify the church in the event of any health changes which would restrict our childs

participation in any activities. We also understand that the adult church representatives reserve theright to restrict our child from any activity that they do not feel is within the physical capabilities of my

child.

Home phone _________________ Fathers work #_______________Fathers mobile #______________

Mothers work #____________________ Mothers mobile #____________________

Email_______________________________________________________________

Emergency contact name ______________________________________________________________

Contact phone number ________________________________________________________________

Family doctor ________________________________________________________________________

Doctors phone number ______ _________________________________________________________

Childs insurance company _____________________________________________________________

Policy number _______________________________________________________________________

initial __________ date ____________

Consent

I (We), the undersigned, being the parent(s) or legal guardian(s) of the child named above, do hereby

consent to the participation of my (our) child in an AIM trip during (2010), including swimming, boating,

hiking, sports events, and any other activities customarily associated with an AIM trip. Further, I (we)

certify my (our) child is physically able and adequately trained to participate in such events.

I (We) do authorize my (our) child to participate in any of the above activitiesinitial __________ date ____________

I have honestly and accurately completed all parts of the Parental Consent Form to the best of my ability.

Signatures of Parents/Guardians

Signature ________________________________________________________Date _______________

Print name __________________________________________________________________________


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Parental Consent Forms(continued)

Insurance ElectionI am aware of the hazards and risks to my child associated with serving in a missions capacity. I further

understand that AIM currently requires the insurance coverages summarized below, that the cost of the

insurance is included with the trip, that these coverages are subject to change, and that I am responsible

for obtaining any additional insurance coverages that I consider necessary.

Foreign Trips

$1,000,000 foreign liability insurance

$1,000,000 foreign contingent auto liability insurance

$1,000,000 employers liability

Foreign workers compensation coverage

Medical accident and sickness coverage $100,000/$50,000/$25,000/$10,000 (as determined by trip

leader)

$250,000 per policy year medical assistance including: Emergency medical evacuation

Medically supervised repatriation

Repatriation of mortal remains

The above benefits illustrate the highlights of this insurance. The actual policy wording prevails.

initial __________date ____________

Stateside trips

$10,000 Accident Medical Maximum

$5,000 Sickness Medical Maximum

$2,500 Accident Dental and Physical Therapy Maximum

$25,000 Accidental Death Benefit

$25,000 Accident Coma or Paralyis Benefit

$10,000 Medical Evacuation

$5,000 Repatriation

$5,000 Return of Remains

The above benefits illustrate the highlights of this insurance. The actual policy wording prevails.

Initial __________date ____________

Please select one of the following:

_____ I do not desire any additional insurance coverage other than what AIM currently requires through

Brotherhood Mutual Insurance Company (as shown above).

_____ I do desire additional insurance coverage, and will assume full responsibility for obtaining such

coverage from a private insurance carrier at our expense.

Initial __________date ____________


12/13

Grade ____ First Name __________________________ Last Name ____________________________

2010-2011 Kalamazoo First Assembly Children & Youth MinistriesGENERAL WAIVER OF LIABILITY AND MEDICAL RELEASE

While participating in any ministry at Kalamazoo First Assembly, I understand that I may engage in,

or be exposed to, activities and situations that pose a risk of injury to myself and my property,

including but without limitation to: children and youth services, discipleship, retreats, camps,

planned after church activities and other similar events. I understand that my participation in the

above-mentioned activities may involve risk of injury to myself and my property, and that no

amount of precaution by Kalamazoo First Assembly can eliminate such risk. Because of this, and in

consideration of Kalamazoo First Assemblys willingness to allow me to participate in such activities,

I agree as follows:

1. I will participate in a careful and prudent manner and will attempt whenever possible to minimize

the risk of injury to others and myself. I agree to obey our Pastors and Leadership and any directives

that they may give me as an individual or as part of a group.

2. I agree to exercise a reasonable degree of care to protect the safety of myself and others whileparticipating in activities, including but not limited to, services, discipleship, retreats, camps,

planned after church activities and other events.

3. I hereby release Kalamazoo First Assembly, its agents, officers, employees and trustees, from

liability for any injury to myself or my property suffered at, or arising out of activities or events,

including any such injury to my person or property resulting from any cause other than the gross

negligence or intentional misconduct of Kalamazoo First Assembly, its agents, officers, employees,

or trustees. I give this waiver and release intending to legally bind myself and my heirs,

representatives, successors and assigns.

4. If, during the course of my participation in the above-mentioned events or otherwise, I notice anysituation which I believe causes a significant risk of injury to others or myself, I will promptly

verbally notify either Kalamazoo First Assemblys Leadership or Kalamazoo First Assemblys

Business Administrator of the situation in writing. Kalamazoo First Assemblys address is 5550

Oakland Dr. Portage, MI 49024.

5. I intend for this Release to stay in effect for so long as I am participating in Kalamazoo First

Assembly during the 2010-2011 Program year.

I/WE HAVE CAREFULLY READ THIS RELEASE AND WAIVER OF LIABILITY. I/WE UNDERSTAND ITS

TERMS AND HAVE SIGNED VOLUNTARILY.

Signed __________________________________________________ Date______________

participant

Signed __________________________________________________ Date______________

parent or guardian

PLEASE FILL OUT THE FOLLOWING PAGE FOR MEDICAL RELEASE INFORMATION


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MEDICAL RELEASE FORM

No Presently Taking Medication?

Yes________________________________________________________________________________

No Require Special Diet/Food?

Yes________________________________________________________________________________

No Allergies? Bee Stings?

Yes________________________________________________________________________________

No Behavioral/Emotional Considerations?

Yes________________________________________________________________________________

No Physical Limitations

Yes________________________________________________________________________________

No Recent Illness or Injury?

Yes________________________________________________________________________________

No Recent Exposure or Contagious Diseases?

Yes________________________________________________________________________________

SPECIAL CONDITIONS

Reaction to Drugs_________________________________________

Fainting

Sleepwalking

Other_____________________________________________________

I authorize Kalamazoo First Assembly to consent to emergency medical or surgical treatment of

my son/daughter, and to routine, non surgical medical care. I also agree to pay for the

performance of such treatment, anesthetics, and operations as deemed necessary in the opinion

of the attending physician.

____________________________________________________________________________________________

Printed name of parent or guardian

____________________________________________________________________________________________

Signature of parent or guardian

Phone: (H)________________________________________ (W)_________________________________________

Health Ins. Co:_________________________________Policy Number: ___________________________________

PLEASE REMEMBER TO SIGN THE FRONT OF THIS FORM

El Salvador Application

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