ETHIOPIA SHORT TERM MISSION TRIP
OCTOBER 2014
Completion of this application does not necessarily guarantee a place on the mission
trip. Each application will be reviewed by the Missions Director and/or the Team
Leader for the trip.
SHORT TERM TRIP APPLICATION (one per person) + answers to 5 narrative questions.
 SIGNATURES OF AGREEMENT
 $100/PERSON DEPOSIT (payable by check made out to Trinity OR on-line at
www.TrinityConnection.com - Ministries/Trinity Outreach/Trip Opportunities)
 COLOR COPY OF PASSORT - 1
ST
two pages/photo page, for each person
(Note: If your passport expires before MARCH 2015, it will need to be renewed before this trip)
 TRINITY MEDICAL & LIABILITY RELEASE FORM (one per person – complete form appropriate to your age)
__________________________________________________________________________________________
This packet is due to the Mission/CE office by _____________________.
You will hear back about the status of your application by
_____________________________________.
_________________________________________________________________________________________
Please drop off or send your completed application packet to the Trinity CE Office, ATTN: Janis Kerr.
For information, email [email protected].
TRINITY UNITED PRESBYTERIAN CHURCH
SHORT-TERM TRIP APPLICATION
PERSONAL DATA:
Name (as it appears on your passport):___________________________________________________
Address: __________________________________________________________________________
City: _____________________________________ State: ___________ Zip: _________________
Telephone: (home) __________________________ (cell) __________________________________
Email: ___________________________________________________ Gender: ⃞ Male ⃞ Female
Birthdate: _____/_____/_____
Birthplace: ______________________________________________
PASSPORT INFORMATION: If you do not have a passport, or if you passport expires before
February 2015, please apply for one/apply for renewal as soon as you hear that you have been accepted
on this trip. Please submit the information requested below immediately after receiving a passport.
Date of Issue: ______________________________ Place of Issue: __________________________
Passport Country & Number: _________________________________________________________
Expiration Date: _______________________ Birthplace: _________________________________
Note: Attach a copy of your passport to this packet and submit to the Missions & CE Office.
HEALTH INFORMATION: Trinity requires that each short-term mission team member have travel
insurance. Some mission trips may have travel insurance included in the cost. Your team leader will
inform you if you need to purchase travel insurance separately.
General Health: ⃞ Excellent ⃞ Good ⃞ Fair
Do you have any allergies? ⃞ Yes ⃞ No
Physical challenges? ⃞ Yes ⃞ No
Dietary restrictions? ⃞ Yes ⃞ No
Emotional challenges? ⃞ Yes ⃞ No
If yes, explain below. Use an additional sheet if necessary.
________________________________________________________________________
________________________________________________________________________
Are you currently under a physician’s care and or receiving prescribed medication of which we should
be aware? ⃞ Yes ⃞ No
If yes, please explain and list medications:
________________________________________________________________________
Page 1 of 3
Are you covered by illness and accident insurance? ⃞ Yes ⃞ No
Does it cover out of state/country travel? ⃞ Yes ⃞ No
Name of your insurance Company: ____________________________________________
Policy Number: __________________________________________________________
Emergency Insurance Contact Number: ________________________________________
Are there any other special considerations we should know about in processing your application?
If so, please list:
________________________________________________________________________
________________________________________________________________________
In case of emergency, please notify:
Name: ___________________________________ Relationship: __________________
Address: _______________________________________________________________
City: __________________________________ State: ___________ Zip: ___________
Home Phone: ____________________________
Cell: _________________________________
Check any of the skills below that apply to you. Give further explanation if necessary:
Construction
⃞Carpentry
⃞Masonry
⃞Plumbing
⃞Electrical
Personal Ministry
⃞Bible Study Leader
⃞Evangelism
⃞Singing (soloist)
⃞Musical Instrument
⃞Children VBS
Computer
⃞Programming
⃞Data Entry
⃞Word Processing
Medical
⃞Doctor
⃞Nurse
⃞Dentistry
⃞Nutrition
⃞Other
Other
⃞Horticulture
⃞Agriculture
⃞Arts/Crafts
⃞Food Service
⃞Other:
Second Languages:
List any languages other
than English you can
speak and your
proficiency level:
Business
⃞Accounting
⃞Management
⃞Marketing
On a separate sheet of paper please answer each of the following:
1. Why do you want to go on this trip?
2. What are the realistic roadblocks that might keep you from going?
3. Have you gone on any short-term teams before?
4. Which staff member or ministry leader knows you well?
5. Please describe your faith journey.
Page 2 of 3
SIGNATURES OF AGREEMENT
Please sign the three sections below and return to Trinity’s Mission Department along with your
Short Term Trip Application and Medical /Liability Release Form.
Financial Agreement
I understand that in attending this trip I am responsible for full payment. Any funds raised above the required trip
costs will go toward the overall team expenses. If for any reason I am unable to fulfill the commitment to go on
the mission trip, I will be responsible for all pre-paid expenses incurred on my behalf (i.e. airfare, lodging,
training expense, etc.). Should this be the case, it is my responsibility to communicate to my donors regarding
my inability to participate in the mission and to assure them that the funds will be used for the intended mission
trip by the team.
By signing this agreement I affirm the paragraph above and note that I have read through the Mission Trip
Financial Policy (see page 2 of the Short Term Mission Trip: Team Member Information Packet) and agree
to adhere to the guidelines.
Signature: ___________________________________________ Date: ______________________
Signature of Parent/Legal Guardian (if participant is under 21)
Personal Covenant
In signing below, I indicate that I have read, understood and accepted all of the conditions outlined in the
Personal Covenant for Short Term Mission Trips with Trinity (see page 4-5 of the Short Term Mission Trip:
Team Member Information Packet)
Signature
Date:
Signature of Parent/Legal Guardian (if participant is under 21)
Volunteer Waiver
As a volunteer for a Trinity Mission Ministry Activities, I understand, acknowledge, and agree to the following:
1.
Participation may include travel to and work in areas of the world characterized by hazardous conditions,
possibly including risks such as land mines and unexploded ordinances, sniper fire, unstable governance and
security, damaged buildings, exposed electrical wiring, contaminated food and water, disease, and poor medical
care. Furthermore, in light of recent acts of terrorism in the United States, the State Department has issued a
public announcement, dated September 12, 2001, entitled, “Worldwide Caution,” in which U.S. citizens are
urged to maintain a “high level of vigilance and to increase their security awareness” while traveling abroad.
The public announcement further warns that U.S. citizens may be targets of terrorist acts.
2.
My life and medical insurance coverage may have exclusions for death, illness, or injury occurring in high warrisk or international destinations. I acknowledge that I am responsible for and have been advised to acquire
appropriate travel or war-risk life and health insurance for the duration of the project activity and that I am
responsible for my own medical and life insurance coverage.
3.
I understand and hereby fully assume all risks and liabilities which may result from my participation as a
volunteer. I release and forever discharge and hold harmless Trinity United Presbyterian Church, it’s
employees, representatives, and agents from any and all actions, claims, and liabilities arising out of injury to or
damage sustained by me. Further, in the event of injury to me, I hereby consent to and authorize medical
treatment and tests considered advisable or necessary in the judgment of any qualified medical personnel.
Signature: ___________________________________________ Date: ______________________
Signature of Parent/Legal Guardian (if participant is under 21)
Page 3 of 3
MEDICAL AND LIABILITY RELEASE FORM — COLLEGE/ADULT
Trinity United Presbyterian Church 13922 Prospect Ave. Santa Ana CA 92705 (714) 544.7850
Name
Last
Address
Birthdate
First
Street and Number
Age_____________________________
(in Fall 2014)
City
Student's Home Phone
Email
Father
Phone H (
)
Mother
Phone H (
)
Zip
______
Cell (
)
Cell (
)
In Emergency, Notify:
Phone (
)
Doctor
Phone (
)
Allergic reactions:  Drugs
 Insect stings
W(
W(
)
 Male
)
 Female
Other
If you have checked any of the above, please give details (i.e., include normal treatment of allergic reactions).
Date of last tetanus shot:
Medications: Name:
Dosage/ Times:
Any swimming restrictions  Yes  No
Any activity restrictions?  Yes
 No
Please explain if answer was yes
Our church's insurance is only secondary insurance. If you have medical insurance, your carrier will be billed for medical charges in the
case of illness or injury while your son or daughter is on a church-related activity.
Do you have health insurance?  Yes
 No
Insurance Company
Policy Number
MEDICAL RELEASE
"In the event that I cannot be reached in an emergency during the dates specified on this form, I hereby give my permission to the physician
or dentist selected by the church leadership to secure proper intervention, X-ray examination, medical or surgical diagnosis and treatment,
anesthesia, and hospitalization for my son or daughter as deemed necessary. I authorize church staff or volunteer staff to give the following
generic, over- the-counter medications as directed by the labels provided by the manufacturer for my child: Analgesics (ibuprofen or
acetaminophen), antihistamines (Sudafed, Benadryl , etc) antibiotic ointment, hydrocortisone cream (such as Cortaid), electrolyte
replacement fluids (such as Gatorade), antiseptic skin and wound cleansers, analgesic balms or gels, sunscreens, with the exception
of:___________________________”
LIABILITY RELEASE
Every activity sponsored by this church is carefully planned and adequately supervised by mature adults. However, even with the best
planning and precautions, unforeseen events can occur. By signing this form the parent or guardian agrees to assume and accept all risks
and hazards inherent in church-related social activities. They also agree not to hold this church (TUPCSA) or its employees or volunteer
assistants liable for damages, losses or injuries to the person or property undersigned. The parents or guardians understand that they are
signing for the minor listed on this form and the signature is for both a medical and liability release.
By signing this form, I am authorizing permission for my photo to be used in Trinity publicity.
Parent or Guardian’s signature if UNDER 18 years old:
IF OVER 18 YEARS OLD SIGN BELOW:
___
Mother/Father
Guardian
Valid from
IMPORTANT:
Rev. 3/12
May 1, 2013
Date Signed
to
____
___
____
June 30, 2015
Please notify the Family Ministries Office (714/505-6254 ext 101 or 119) if your student is exposed to any communicable
diseases during the three weeks prior to camp attendance.
MEDICAL AND LIABILITY RELEASE FORM – CHILDREN
Trinity United Presbyterian Church 13922 Prospect Ave. Santa Ana CA 92705 (714) 505.6254
Name
Last
Address
Birthdate
First
Street and Number
Grade____________________
(in Fall 2014)
City
Student's Home Phone
Zip
Email
Father
Phone H (
)
Mother
Phone H (
)
 Male  Female
Cell (
)
Cell (
)
In Emergency, Notify:
Phone (
)
Doctor
Phone (
)
Allergic reactions:  Drugs
 Insect stings
W(
W(
)
)
Other
If you have checked any of the above, please give details (i.e., include normal treatment of allergic reactions).
Date of last tetanus shot:
Medications: Name:
Dosage/ Times:
Any swimming restrictions  Yes  No
Any activity restrictions?  Yes
 No
Please explain if answer was yes
Our church's insurance is only secondary insurance. If you have medical insurance, your carrier will be billed for medical charges in the
case of illness or injury while your son or daughter is on a church-related activity.
Do you have health insurance?  Yes
 No
Insurance Company
Policy Number
MEDICAL RELEASE
"In the event that I cannot be reached in an emergency during the dates specified on this form, I hereby give my permission to the physician
or dentist selected by the church leadership to secure proper intervention, X-ray examination, medical or surgical diagnosis and treatment,
anesthesia, and hospitalization for my son or daughter as deemed necessary. I authorize church staff or volunteer staff to give the following
generic, over- the-counter medications as directed by the labels provided by the manufacturer for my child: Analgesics (ibuprofen or
acetaminophen), antihistamines (Sudafed, Benadryl , etc) antibiotic ointment, hydrocortisone cream (such as Cortaid), electrolyte
replacement fluids (such as Gatorade), antiseptic skin and wound cleansers, analgesic balms or gels, sunscreens, with the exception
of:___________________________”
LIABILITY RELEASE
Every activity sponsored by this church is carefully planned and adequately supervised by mature adults. However, even with the best
planning and precautions, unforeseen events can occur. By signing this form the parent or guardian agrees to assume and accept all risks
and hazards inherent in church-related social activities. They also agree not to hold this church (TUPCSA) or its employees or volunteer
assistants liable for damages, losses or injuries to the person or property undersigned. The parents or guardians understand that they are
signing for the minor listed on this form and the signature is for both a medical and liability release.
By signing this form, I am authorizing permission for my child’s photo to be used in Trinity publicity.
Parent or Guardian’s signature:
___
Mother
Guardian
Valid from
IMPORTANT:
Rev. 3/13
May 1, 2013
Date Signed
to
Father
___
____
____
June 30, 2014
Please notify the Family Ministries Office (714/505-6254 ext 101 or 119) if your student is exposed to any communicable
diseases during the three weeks prior to camp attendance.