Mission Trip Application - Fellowship Olathe

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Fellowship Olathe

Mission Trip Application

Please fill out the application below to sign up for an upcoming mission trip

Mission Trip You Are Applying For*

Name as it Appears on Passport*
First Middle Last
Date of Birth*
Month
Day
Year
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email*
Phone*
In case of emergency notify*
First Last
Emergency Contact Phone*
USA Passport Number
Exp. Date
Month
Day
Year
Issue Date
Month
Day
Year
Do you have a passport that is valid 6 months after the trip?
- Yes
- No
T-shirt size*

Have you ever been convicted of a misdemeanor or felony?*
- Yes
- No
If yes, please list when, what for and what was the result
Have 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 result
Are you a member of Fellowship Olathe*
- Yes
- No
If no, explain why you haven't joined
When 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 explain
Do 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 list
Are you currently under medication prescribed by a doctor?*
- Yes
- No
If yes, please list the medication(s) and what it's for
Have 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 taking
List any previous operations
List any special diet or special needs
Please 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*
Does your insurance cover you overseas?*
- Yes
- No
Insurance Co.*
Policy #*
Group #*
Insurance Phone Number*
Subscriber Name
First Last
Subscriber Phone Number
Subscriber Place of Employment
Subscriber Occupation
Work Phone
Permission 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 Fellowship Olathe, 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 Fellowship Olathe 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 Guardian
Phone
This field is for validation purposes and should be left unchanged.


Contact

Brian Richardson

Associate Pastor
913.953.8320
brichardson@fellowshipolathe.com

We exist to share the love and salvation found in Jesus Christ with our neighbors, our community, and the world.

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901 N Parker St
Olathe, KS 66061

913.953.8320

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Olathe, KS 66061

913.953.8320

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Time You're Coming
Would you like to preregister any kids? (6 Weeks-5th Grade)*
Please list kids name, date of birth, grade, and any allergies/special needs.
Would you like to preregister any youth? (6th-12th Grade)*
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