CCM Application Page 1 Chosen Children Ministries Short-Term Mission Application PASSPORT Name: _______________________________ Name you go by: _________________________ Passport Number: ________________________________ Full address: ________________________City____________________State______ Zip code___________ Telephone number(s): Home: (_____)______________________ Cell#: (_____)______________________ Church attending: ____________________________ Member? Yes No T-shirt size: Small Medium Large X-Large XX Large XXX Large Email address (please print clearly): ________________________________Occupation: _______________ Do you speak Spanish? Yes No Date of birth: Month: _______ Day: _____ Year: _______ Emergency Contact: ______________________________________________________________________ Name Telephone Number List any medical problems and medications: _________________________________________________ ________________________________________________________________________________________ ________________________________________ Blood type: _____________________________ Reasons for going on a short-term mission trip:_______________________________________________ ________________________________________________________________________________________ Travel Accident Insurance Beneficiary (please complete): ________________________________________________________________________________________ Name Relationship Have you received and read the CCM Guidelines in the team member brochure? Yes No ACKNOWLEDGMENT, ASSUMPTION, AND RELEASE I, the undersigned, wish to participate in a short-term mission project in Nicaragua conducted under the auspices of Chosen Children Ministries (“CCM”). By signing this form, I acknowledge (1) that traveling to and in the Country of Nicaragua involves hazards not customarily encountered when traveling in America. (2) Medical facilities in Nicaragua are substandard and that should a medical emergency develop during my trip, it is unlikely that I will receive medical care in Nicaragua equivalent to that available in America. (3) Working conditions in Nicaragua are often inferior to conditions in America. (4) CCM does not carry insurance to insure against any of the risks I may encounter in Nicaragua. Despite the foregoing, it is my desire to participate in the work in Nicaragua, and I knowingly assume the risks that are involved and release CCM, its employees and agents, from any liability for injury, damage, or harm which may occur to my person or property while traveling in connection with this project or otherwise participating in this project. I affirm that I am eighteen (18) years of age or older, or the parent/guardian of the participant if under eighteen years of age, and that this Acknowledgment, Assumption, and Release is binding on me and my executor, administrators, and heirs. I give CCM and its representative (s) with me on any such trip authority to request and authorize medical and/or hospital treatment for my benefit in the event of any injury or sickness sustained by me while on such ministry activity, including, without limitation, while traveling to and from any foreign country. I agree to pay for all such treatment and to reimburse CCM for all costs and expenses incurred by it with respect to such treatment. ________________________________ Date: ____________ Sworn to and subscribed before me this ________day of ___________, 2010 Signature of Applicant _________________________________ Notary Public ________________________________ Signature of Parent or Guardian of Minor Applicant (If applicable) My commission expires: _____________ CCM Application Page 2 Chosen Children Ministries Authorization to Use or Disclose Protected Health Information As required by Privacy Regulations, Chosen Children Ministries may not use or disclose your protected health information without your authorization. I hereby authorize Chosen Children Ministries and any of its employees to use or disclose the health information provided to CCM to medical professionals, medical institutions, or CCM short-term mission team members in Nicaragua or in the US and to act on my behalf in case of a medical emergency. Health Information authorized to be disclosed includes medications, health conditions, allergies, and all other health information provided to Chosen Children Ministries. Effective dates for this authorization: __________________ through _____________ . Date team departs for Nicaragua One day after trip return date This authorization will expire at the end of the above period. ________________________________ ______________________ Signature of team member or Authorized Representative (indicate relationship) Date Team Name / Church __________________________________ Team Leader __________________________________