Note: Submitting an application to join a mission team is NOT a guarantee that the applicant will be part of the team.

UALC Missions Trip Application

Mission Trip Type? *

Domestic

International

For which trip are you applying? *

For which international trip are you applying? *

Personal Information

First Name: *

Last Name: *

Today's Date: * +

Street Address: *

City: *

State: *

Zip Code: *

Home Phone Number: *

Work Phone Number:

Email Address *

Date of Birth: * +

Country of Birth: *

Country of Citizenship: *

Do you have a passport? *

Yes

No

Passport Number: *

Date Issued: * +

Expiration Date: * +

Marital Status *

If Married, Spouse Name: *

In Case of an Emergency, Please Notify: *

Relationship to Me: *

Street Address: *

City: *

State: *

Zip Code: *

Home Phone Number: *

Work Phone Number:

Email Address *

Health

How would you describe your present health? *

Excellent

Good

Average

Poor

Please state any major illness(es) you have had in the last five years (Enter 'NA' if it doesn't apply): *

Please list all medications you are currently taking (Enter in 'NA' if it doesn't apply): *

Please list all allergies you have (Enter in 'NA' if it doesn't apply): *

Primary Physician First and Last Name: *

Primary Physician Phone Number: *

Are you presently under the care of a physician? *

Yes

No

If yes, please explain: *

Are you a smoker? *

Yes

No

Field of Service

Do you speak any foreign languages? *

Yes

No

If yes, please list and indicate level of proficiency: *

Please indicate any skills, talents, or experience that you feel may be helpful on the field: *

Please list previous missions experiences:

	Country	Church/Mission Organization	Dates of Project	Ministry
1.	Country	Church/Mission Organization	Dates of Project	Ministry
2.	Country	Church/Mission Organization	Dates of Project	Ministry
3.	Country	Church/Mission Organization	Dates of Project	Ministry
4.	Country	Church/Mission Organization	Dates of Project	Ministry
5.	Country	Church/Mission Organization	Dates of Project	Ministry

Will you need help raising funds for this trip? *

Yes

No

Church Involvement

Are you a member of UALC? *

Yes

No

If no, what church are you a member of? *

Are you currently part of a small group? *

Yes

No

If yes, who is the leader of the group? *

Please list the ministries with which you have been involved. (Please list time of involvement, any leadership positions held, and the organization/church, and contact individual which was responsible for the ministry.) *

Your Story

In the space provided, please share your relationship with God. *

Motivation

Please explain briefly what you hope to experience on this mission project and explain why you want to participate. *

References

Reference 1

Please provide two references.

First Name *

Last Name: *

Relationship: *

Street Address: *

City: *

State: *

Zip Code: *

Best Contact Phone Number: *

Alternate Phone Number:

Reference 2

First Name *

Last Name: *

Relationship: *

Street Address: *

City: *

State: *

Zip Code: *

Best Contact Phone Number: *

Alternate Phone Number:

Commitment

If selected to be a part of a UALC Team, I make a commitment to:

Go through the training process prior to departure and after I return from the trip.
To conduct myself in a manner worthy of the Lord while serving Him on the project.
Submit to the team leader’s and the host on-the-field’s authority.
Refrain from any behavior which may compromise my witness (i.e.: abusive language, drug use, etc.)

I authorize the Mission Team Leadership to contact my physician in the event that questions about my health/condition arise. Additionally, if at any time while on the project my behavior, health, or nondisclosed information constitutes a problem, the team leader has the authority to ask me to return home. Any additional costs incurred as a result of this action will be at my cost.

Your Signature: *

Date Signed: * +