2015 Youth Ministry Summer Missions
SECONDPRESBYTERIANCHURCH
4055 Poplar Ave, Memphis, TN38111
phone: (901)454-0034 ext.116 email:
APPLICATION FOR YOUTH MISSION TRIP
Your completed application form must be received in the Youth Office by Sunday, December 21, 2014. Please include a $100 check to Second Presbyterian Church. If you are accepted, your deposit will be applied towards the cost of the trip. If you are not accepted, your deposit will be refunded. No application will be accepted without the application fee and a completed medical release form.
Name:______Date of Birth:______
Home Phone:______Cell Phone:______Email:______
Address:______
(city) (state) (zip)
SSN:______School/Grade/Occupation:______
Are you a member of Second?____ If not, home church:______
Do you have a valid passport?____ (If “yes,” list # and expiration date. If “no,” please get an application from the post office if you are accepted and submit it promptly). ______
For what trip are you applying? (complete descriptions can be found at 2pcyouth.org under “TRUE NORTH” and then “Mission Trips”) Please list 1,2,3 in order of preference;1 being your 1st preference.
___ Baltimore (May 23-30)
- Approximate cost: $950
___ Mexico (June 27-July 4)
-Approximate Cost: $1700
___ Budapest, Hungary (June 30- July 12)
- Approximate cost: $2900
Please type out your answers to the following questions and attach them to this application:
1. Briefly share how you came to a personal faith in Jesus Christ.
2. Use one word to describe your relationship with the Lord this year. Explain why.
3. Describe the last time you shared the Gospel with someone, in detail.
4. Why do you want to serve on a mission team this year?
5. What do you hope to gain from this mission experience?
6. What do your parents think of you going on this trip?
7. Briefly explain why you put the trips in the order that you did.
8. Give the name, address and phone number of two people (not relatives) who could give an honest evaluation of your relationship to Jesus Christ and your ability to serve others.
- ______
(name)(phone)
(address)
2.______
(name)(phone)
(address)
9. Do you have any allergies, illnesses or other health problems which would affect your
performance on this team? (For example, are you taking any medications of which your leaders need to be aware?) If yes, please explain:______
10. The date of your last tetanus shot: ______(An up-to-date tetanus shot is mandatory)
11. I certify that I have health insurance and have listed the information at the end of this application. I understand that in case of accident or illness, my insurance will be the primary source of payment of expense incurred. ______
(please initial)
12. I am under 18 years of age or am still on my parents’ insurance and my parents have signed the waiver on the last page of this application and have included their health insurance information conditions listed in number 18 above. ______
(please initial)
IMPORTANT INFORMATION
In case of emergency, please contact the following people:
- ______
(name)(address)
______
(home phone number)(work phone number)
- ______
(name)(address)
______
(home phone number)(work phone number)
Physician’s Information:______
(name)(phone)
(office address)
Insurance Information:______
(carrier name)(policy #)
Second Presbyterian Church
4055 Poplar Avenue, MemphisTN 38111
Phone: 901 454-0034
RELEASE FORM
Project Location ______Project Dates ______
Participant’s Name ______
Birth Date (mo/day/yr) ______Phone______
Address______
City, State, Zip: ______
Alternate Emergency Contact and Phone ______
Insurance for all participants
- ACCIDENT INSURANCE (does not cover losses of personal property)
I understand that Second Presbyterian Church provides a $50,000 Accident Medical Coverage, which includes $10,000 Accidental Death. Emergency evacuation expenses are included when necessitated, by circumstances occurring more than 150 miles from home. Repatriation expenses are also provided in the event of death. These coverages are provided for all participants in the short term program and are included in the trip cost. There is a $100 deductible, and an 80/20 coinsurance.
2. MEDICAL INSURANCE
I also understand that I am responsible for covering any medical expenses incurred on account of sickness, because insurance for sickness is not provided by Second Presbyterian for US projects and only provides a minimal supplementary coverage of $2,500 for International projects.
You must have medical insurance to attend all Second Presbyterian projects. Please indicate your insurance coverage below, check the appropriate box(s):
For All Project Participants:
oI am already covered by my own medical insurance.
oI am covered under my parent’s medical insurance.
oI do not have medical insurance, but am applying for short term coverage. (Confirmation one month before trip).
For International Project Participants:
oI am covered by my own medical insurance and have confirmed with my insurance provider that I (or my dependent) am covered while outside the US on this project.
oMy medical insurance does not cover me (or my dependent) outside the US, but I am applying for short term coverage.
FOR ADULT PARTICIPANTS
Medical Consent - for adult participants
I have had a tetanus booster within the past 5 years for International projects; 10 years for US projects
_____Yes _____No, but I will have by the beginning of the project.
In the event of a medical emergency, I hereby consent to the necessary and proper treatment, surgery, and/or anestheticby a licensed physician or health care professional for myself.
Signature of (adult) participant: ______Date ______
Release of Liability - for adult participants
I am aware of the potential risks to myself and my property as I participate in Second Presbyterian’s Short Term Missions Program. With such knowledge, I voluntarily release Second Presbyterian, their representatives and employees
from any and all liability related to the activities of this program.
Signature of (adult) participant ______Date ______
FOR MINORS AND THEIR PARENTS
(Both parents must sign each section - Do not leave parental signature lines blank without explanation.)
1.Permission for Travel - for a minor
As a parent or guardian, I give my permission for (name): ______
to travel to (location): ______to participate in Second Presbyterian’s Short Term Missions Program on the following dates (from): ______(to):______, 20 _____
Both parents must sign
Father: ______Date ______
Mother: ______Date ______
Other Legal Guardian* ______Date ______
*indicate relationship to participant: ______
2.Medical Consent - for a minor
My child has had a tetanus booster within the past 5 years for International projects: 1-10 years for US projects. _____YES _____NO, but he/she will have by the beginning of the project.
In the event of a medical emergency, I hereby consent to the necessary and proper treatment, surgery, and/or anesthetic by a licensed physician or health care professional for (name): ______
Both parents must sign
Father: ______Date ______
Mother: ______Date ______
Other Legal Guardian* ______Date ______
*indicate relationship to participant: ______
3.Release of Liability - for a minor
I am aware of the potential risks to my child and his/her property as he/she participate(s) in Second Presbyterian’s Short Term Missions Program. With such knowledge, I voluntarily release Second Presbyterian, their representatives and employees from any and all liability related to the activities of this program.
Both parents must sign
Father: ______Date ______
Mother: ______Date ______
Other Legal Guardian* ______Date ______
*indicate relationship to participant: ______