PERSONAL INFORMATION:

Full Name (As it appears on your passport)

Address

City   State   Zip

Country   Gender  M   F 

Home Phone  Cell Phone

Email Address

Professional Position and Interest

HEALTH and TRAVEL INFORMATION:

Name and Date of Trip La Ceiba April 13 - 21, 2012LAMB Institute July 21-28, 2012   Frequent Flyer #

Emergency Contact::   Name    Number    Relation  HusbandWifeMotherFatherDaughterSonBrotherSisterAuntUncleNeighborFriendOther

Have you ever been on a mission trip before?   Y   N

Do you speak any foreign language?    Y  N

If yes, which one(s)?   

Do you need MPPC to provide Volunteer Missionary Travel Insurance?  Y  N

If yes: 

Medications    Allergies   Blood Type

Name of Beneficiary:

Email of Beneficiary:  

Phone of Beneficiary:     Relationship of Beneficiary BrotherDaughterFatherFriendHusbandMotherSisterSonWife

If no:

Name & Phone Number of Insurance

MPPC strongly suggests that you visit your family physician before any trip.

PASSPORT INFORMATION:

Passport Number

Date of Issue  JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember  12345678910111213141516171819202122232425262728293031  20012002200320042005200620072008200920102011    Expiration Date JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember  12345678910111213141516171819202122232425262728293031  2000200120022003200420052006200720082009201020112012201320142015201620172018201920202021

Place of Issue

Date of Birth JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember  12345678910111213141516171819202122232425262728293031  19301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000

Please send a copy of your passport via email or mail to MPPC 302 Hibben St Mount Pleasant, SC 29464 

FINANCIAL CONSIDERATIONS:

I agree to pay $  Yes, I would like to apply for a SCHOLARSHIP APPLICATION in the amount of $

FAITH STATEMENT:

Why do you want to participate on this trip?

What are your concerns and expectations for this trip?

COVENANT:

I Covenant to meet with the team at least four times before we leave on the trip and at least once when we return.

• I understand that I will have to pay the full sum of the trip cost, but that the church does have financial assistance if needed.
• I will be a representative of Jesus Christ and MPPC on this mission trip experience.

I have read and agree to the Covenant:   Date