NAME AS IT APPEARS ON YOUR PASSPORT
(This is the name we will use for an airline ticket, so it must be exactly as it appears on your passport):
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Address:
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City:
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Zip Code:
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State:
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Home Phone:
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Work Phone:
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Cell/Pager Phone:
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Email:
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Marital status:
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Date of Birth:
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Age:
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Male or Female:
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Nickname:
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Citizen of what country?
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Do you have a valid passport?
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Issued by what country?
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| HEALTH INFORMATION: |
Do you have or have you ever had:
Fainting Spells
Heart Problems
Diabetes
Respiratory Problems
Seizures
Eating Disorder |
Do you have any condition that might affect your ability to participate in this trip (e.g., fear of flying, depression, anxiety, sleep disorders)? |
Do you have any chronic illnesses or allergies?
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Are you presently taking medication prescribed by a doctor?
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If so, which medications?
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Have you ever had any psychiatric care or treatment?
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Please list any hospitalization history.
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At times we send teams to remote areas of the world where there are potential health hazards and risks, limited hygiene facilities, extreme weather, and very basic living conditions. What physical limitations or health condition(s) may limit your participation under these conditions?
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Does your health insurance cover you overseas?
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How would you describe your health and fitness
* You may be required to provide a doctor’s letter of “clearance” before traveling. |
| TALENTS: |
Please list any talents that you have
(drama, singing, instruments, medical, teaching, construction, etc.)
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Do you speak any foreign languages fluently?
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What do you see as your strongest character quality and why?
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What do you see as your weakest character quality and why?
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| PERSONAL INFORMATION: |
What are your personal expectations for this trip? What would make this trip a success for you?
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Love in Motion-Global hopes to foster an atmosphere of team unity and cohesiveness that will strengthen the ability of the team to work together. How do you hope to contribute to the cohesiveness of the team? What personal characteristics helped in past experiences where a group effort was essential?
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If you are dating or engaged to someone, is this person applying to be a part of this team?
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How does your family feel about your participation on this trip?
Their response to your decision was:
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What are the most significant events that have occurred in your life in the past two years?
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In some cases, team members may voluntarily assemble for prayer and devotions. Please explain your opinions and/or feelings on this matter.
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Have you been involved with any of the following within the past year?
Alcohol
Illegal drugs
Criminal activity
Tobacco
Cult or the occult
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Have you ever been convicted of a crime? (If yes, please explain)
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I have reviewed the schedule of team meetings (via internet and telephone), and I commit to attend ALL scheduled meetings (one face-to-face meeting).
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If you can’t attend a meeting, please indicate which meeting(s) you will miss and why
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Do you have any questions or concerns regarding this trip that you would like answered at this time?
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Non-Refundable Deposit of $500 per-person.
Deposit due by August 1, 2008. Full payment due September 1, 2008. (Total trip costs fluctuate; please contact Love in Motion-Global for updated information regarding current costs). |
