Application Form

SUMMER EXPEDITION - NORTHERN ASIA (MAY, 2019 specific dates TBD depending on flights)

Full Name *
Full Name
Mobile Number *
Mobile Number
Gender at birth *
Address *
Address
Emergency Contact. *
Emergency Contact.
Mobile Number *
Mobile Number
Home Number
Home Number
Address *
Address
Do you have a current passport? *
List any allergies you may have.
List any medical conditions that would affect this trip.
Are you currently taking any medication? *
Doctor *
Doctor
Phone Number *
Phone Number
Why are you interested in going on this trip?
Describe your relationship with Jesus and your current devotional life.
Will you personally commit to honor team leaders, staff, church personnel, and those on the mission team? i.e. positive attitude, serve with a cheerful heart and respect others' requests. *
Medical Release. *
In the event of an injury or illness in which I become incapacitated and am unable to make medical decisions for myself, and Chi Alpha team leaders or their approved associates are unable to reach my emergency contact and/or my doctor, I authorize them to seek all necessary medical decisions on my behalf. I understand that Chi Alpha Campus Ministries and any of their associates will not be held responsible for any medical expenses incurred on the basis of this authorization.
If you agree with the above statement
If you agree with the above statement
Signature: By typing my name in the box below, I understand that it will serve as my legal and binding signature.
Date *
Date
Liability Release. *
With the intention of being legally bound, the undersigned hereby releases from liability and agrees to indemnify and hold harmless Chi Alpha Campus Ministries and its employees, representatives, and agents (responsible for arranging travel and overnight housing), for any and all liability for personal injuries (including death), property loss or damages resulting from activities, travel, overnight housing, and accommodation for this trip. The undersigned agrees to abide by all the rules and the regulations promulgated by Chi Alpha Ministries and their elected officials.
If you agree with the above statement
If you agree with the above statement
Signature: By typing my name in the box below, I understand that it will serve as my legal and binding signature.
Date 1 *
Date 1
Agreement & Signature. *
By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted, and false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.
If you agree with the above statement
If you agree with the above statement
Signature: By typing my name in the box below, I understand that it will serve as my legal and binding signature.
Date 2 *
Date 2