Application For Short Term Mission
Service With Special Needs Ministries

General information:                                                          Please enclose a small photo. 

Full Name :______________________________________________________________________

Present Address__________________________________________________________________

Phone: Home ___________________ Cell ___________________ Work_____________________

Email address: _____________________________________  Fax__________________________

Date of Birth:(mm/dd/yy)__________________ Place of Birth: ______________________________

Citizenship ______________________________________________________________________

Marital Statues: Single______ Married______ Separated______ Divorced______ Widowed______ 

Were you raised in a Christian Home? Yes _______ No _________ 

What is your church background?___________________________

Are you a member of a church? Yes _____ No ______
Name of Church ______________________________

Have you ever worked with Handicapped: Yes _____ No ______
If yes, where and how long have worked with them. What are/were your duties? _______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Name of Pastor _________________________________ Phone #__________________________
Address________________________________________________________________________

Please give the name of two more references whom we may contact. One of them should be your employer/supervisor from your work with the handicapped. If you have worked with the handicapped.
Note: they cannot be relatives.

Name: _____________________________________
Address: _____________________________________________________
Day Time Phone: __________________________________
Evening Phone Number: _____________________________________

Name: _____________________________________
Address: _____________________________________________________
Day Time Phone: __________________________________
Evening Phone Number: _____________________________________

SPECIAL NEEDS MINISTRIES SHORT TERM MISSIONS RELEASE OF ALL CLAIMS

This Agreement and Release is made on this ________ day of __________________, 20_______
between:

____________________________________    ___________________________________
Participant                                             Spouse (if applicable)
or
_______________________________________________________________________________
Parents

The above mentioned participant will be voluntarily participating in a short term missions activity from ________________, 20______   to _____________________, 20___________which is arranged, and supervised, sponsored or in some manner involves Special Needs Ministries. Special Needs Ministries involvement may vary from close supervision, if any, to incidental contact between Special Needs Ministries and the participant.

AGREEMENT

1. The above-mentioned participant, at his own cost, shall arrange for and maintain health, major medical and hospitalization insurance during the period of activity mentioned above. Such insurance shall provide coverage for any and all expenses caused by illness, injury, accident or death.

2. In consideration of the opportunity to engage in such activity, the participant hereby and his or her heir, executors, administrators, successors and assigns, RELEASE, acquit and forever discharge and hold SPECIAL NEEDS MINISTRIES harmless from all claims whatsoever resulting from illness, accident, injury, hospitalization or death of participant arising from any long term missions activity.

3. By his or her signature, the parent of any minor participant and /or spouse of such participant hereby releases his or her heirs, executors, administrators, successors and assigns, RELEASE, acquit and forever discharge and hold Special Needs Ministries harmless from any claims such parent or spouse may have as a result of the illness, injury, accident, hospitalization or death of participant.

4. In addition, all parties to this Agreement further RELEASE, hold harmless and forever discharge any agents, employees, administrators and all other persons who maybe acting on behalf of or in the stead of Special Needs Ministries and with the respect to all activities contemplated herein.

5. The agreement further declare(s) and represent(s) that no promise, inducement or agreement not set forth herein, has been made to the undersigned, and that this Release contains the entire agreement between parties hereto.

6. Furthermore, the undersigned understands that Special Needs Ministries representative, to the best of his ability, will exercise standards of control for the best interests of the group. In the event of an EMERGENCY, the undersigned therefore gives permission for authorized personnel to make any medical or legal decisions as may be deemed necessary. In the event of an EMERGENCY, please contact the following people:

__________________________________   __________________    __________________
Name of Contact/Relationship to Participant        Daytime phone Number     Evening Phone Number

__________________________________   __________________    __________________
Name of Contact/Relationship to Participant        Daytime phone Number     Evening Phone Number

1. Witness to Participant

Signed this ________ day of ___________________________, 20_____ in the Presence of:

Name:___________________________________ Signature:____________________________

2. Witness to Spouse of Participant (if applicable)

Signed this ________ day of ___________________________, 20_____ in the Presence of:

Name:___________________________________ Signature:____________________________

3. Father of Participant (if applicable).

Signed this ________ day of ___________________________, 20_____ in the Presence of:

Name:___________________________________ Signature:____________________________

4.Mother of Participant (if applicable) 

Signed this ________ day of ___________________________, 20_____ in the Presence of:

Name:___________________________________ Signature:_______________________________

".....that at the name of Jesus every knee shall bow.....every tongue confess... Phil. 2:10, 11"