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 Trip AfricaHondurasNicaragua  Date of Trip October 18 - 26, 2008February 6 - 14, 2009

Have you ever been on a mission trip?  Y  N

Do you speak any foreign language?   Y  N 

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, please contact:

Name  Relation HusbandWifeMotherFatherBrotherSisterDaughterSonFriendNeighborOther

Phone Number

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