Back To Missions Domestic Mission Trip Application Please fill out the application below to sign up for an upcoming mission trip Mission Trip You Are Applying For*Select OneHouston, TX | Jul. 12-16 Name* First Middle Last Date of Birth* Month Day Year Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Phone*In case of emergency notify* First Last Emergency Contact Phone* Have you ever been convicted of a misdemeanor or felony?* Yes No If yes, please list when, what for and what was the resultHave you ever been convicted of child abuse or a crime involving an actual or attempted sexual molestation of a child?* Yes No If yes, please list when and what was the resultAre you a member of Lenexa Baptist Church* Yes No If no, explain why you haven't joinedWhen were you saved?* When were you baptized?* What Sunday School class do you attend?* What other ministries are you involved in?* Why do you want to go on this mission trip?* What is your general health?* Excellent Good Fair Poor Do you have any chronic illnesses or allergies to medication?* Yes No If yes, please explainDo you have seasonal allergies?* Yes No If yes, what medication(s) are you taking?Do you have a condition which might affect your ability to fully function as a Missionary? (I.e. fear of flying, depression, anxiety, sleeping disorder)* Yes No If yes, please listAre you currently under medication prescribed by a doctor?* Yes No If yes, please list the medication(s) and what it's forHave you ever had any psychiatric care or treatment?* Yes No If yes, are you currently under a doctor's care or any medication? Please list the doctor's name and the medication you are takingList any previous operationsList any special diet or special needsPlease check the childhood diseases you have had Chickenpox Measles Mumps Whooping Cough Date of Tetanus Immunization Month Day Year Name of Family Physician* Family Physician Phone Number*Insurance Co.* Policy #* Group #* Insurance Phone Number*Subscriber Name First Last Subscriber Phone NumberSubscriber Place of Employment Subscriber Occupation Work PhonePermission for Medical Treatment, Photograph, Release and Indemnity*My permission is granted for the leader in charge of this short term mission trip to administer First Aid, or obtain necessary medical attention in case of sickness or injury to me or my child. Also, I understand that as a participant, myself or my child may be photographed during normal camp or event activities. I, the undersigned, do hereby verify that the above information is correct and I do hereby release and forever discharge Lenexa Baptist Church, from any and all claims, demands, actions or causes of action, past, present, or future arising out of any damage or injury while employed by or participating in this trip. I agree to indemnify Lenexa Baptist Church for any and all claims, demands, damages, injuries, costs, suits or causes of action, past, present, or future, arising out of or causes by myself or my child while participating in this trip. I Agree Complete and sign below*(Youth under 18 years of age requires Parent/Legal Guardian signature)Parent/Legal Guardian10+7= PhoneThis field is for validation purposes and should be left unchanged. Lenexa Baptist Church Visit Our Website Directions Fellowship Olathe Visit Our Website Directions Reach Church De Soto Visit Our Website Directions Contact Kelly Hughes Missions & Cares Pastorkelly@lenexabaptist.com913.627.9331
