Full Name *

First Name

Last Name

Mobile Number *

(###)

###

####

Date of Birth

MM

DD

YYYY

Gender at Birth *

Male

Female

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact. *

First Name

Last Name

Mobile Number *

(###)

###

####

Home Number

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you currently taking any medication? *

Yes

No

Doctor *

First Name

Last Name

Phone Number *

(###)

###

####

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. *

Yes

No

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.

Agree

Disagree

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.

First Name

Last Name

Date *

MM

DD

YYYY

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.

Agree

Disagree

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.

First Name

Last Name

Date 1 *

MM

DD

YYYY

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.

Agree

Disagree

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.

First Name

Last Name

Date 2 *

MM

DD

YYYY