Guatemala Missions Trip 2018 Trip Dates: July 27th – August 7th Total Cost: $1900 Deadlines: • Saturday, April 8th – Application Due • Sunday, April 15th – $700 deposit due (non-refundable) • Sunday, June 3rd – $600 payment due • Sunday, July 1st – $600 payment due *Please make all checks payable to Crossroads Community Cathedral, memo: Guatemala Summer Missions Trip. You can bring payments to Crossroads’ Administrative Offices, or give your payment directly to Derrick Baez during the weekend services.*
Requirements: • Completed application & payments • Valid passport (check expiration date) • Commitment to attend all mandatory team meetings Meeting Dates: • Saturday, February 3rd, 5:00pm (Room 203) *or* Sunday, February 4th, 10:15am (Room 203) – Informational Meetings (choose one to attend) • Saturday, April 14th, 3:00pm (Room 203) – Team Meeting/Orientation • Saturday, May 12th, 3:00pm (Room 203) – Team Meeting • Saturday, June 23rd, 3:00pm (Room 203) – Team Meeting (Packing donations) • Saturday, July 21st, 3:00pm (Room 203) – Final Team Meeting *All team meetings are mandatory. If you are unable to attend all team meetings please speak with P.Sterling or Derrick before you apply as this may affect your eligibility to attend the trip.*
Contact Derrick Baez with any questions (860)895-1231 x 632
[email protected]
Crossroads Community Cathedral 1492 Silver Lane East Hartford, CT 06118
Guatemala Missions Trip 2018 Application APPLICANT INFORMATION DOB Name (Last, first, middle)
Passport #
Street address, City, ST, ZIP Code
Passport Expiration Date
Primary phone number | Other phone number
Email address
Gender: M or F
Parent/Guardian Information (Only completed if under 18) ________________________________________________________________________________ ________________________________ Name (Last, First, middle) Relationship ________________________________________________________________________________ ______________________________________ Primary phone number | Other phone number Email address
GENERAL INFORMATION Are you a participating member at Crossroads? If not, what church? ________________________________________________________________________________________________________________________
Have you ever been on a missions trip? (Please list trip location, church group, year, and any comments you may have.) ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________
Write down YES or NO next to each question. If you answered YES next to any question, please give a detailed explanation. (dates, when the last time you struggled, etc.) Been convicted of a committing a crime? _______________________________________________________ Been involved with illegal drugs or tobacco products?_____________________________________________ Had diabetes or hypoglycemia? _________________________________________________________________ Had seizures or fainting spells? ____________________________________________________________________ Have a serious illness? ____________________________________________________________________________ Have an eating disorder? _________________________________________________________________________ Have breathing problems? _______________________________________________________________________ Had psychiatric care? ____________________________________________________________________________ Taken depression or behavioral meds? ____________________________________________________________ Intentionally inflicted harm on yourself? ___________________________________________________________ Attempted suicide? ______________________________________________________________________________ Been treated for physical or mental impairment? __________________________________________________
MEDICAL INFORMATION I, as the participant, am physically fit for this missions trip. I have read the recommendations from Disease Control regarding vaccinations, immunizations and other precautions for the prevention of disease. I certify that I have followed and am following all procedures (shots, serums, medications, etc.) recommended by our local physician and the above agencies. Medical Questionnaire – Please be very detailed. Attach another page if needed. Is the participant presently being treated for an injury or sickness or taking any form of medication for any reason? YES NO (If yes, please explain.) ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________
Is the participant allergic to any type of medications? YES
NO
(If yes, please explain.)
________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________
Does the participant have any allergies other than medical? YES
NO
(If yes, please explain.)
________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________
Does the participant require a special diet?
YES
NO
(If yes, please explain.)
________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________
Can the participant swim?
YES
NO
Does the participant have ANY physical conditions or illness that could potentially hinder him/her if participating in rigorous activity, such as hiking, walking long distances, lifting heavy objects, etc.? YES NO (If yes, please explain.) ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________
I certify that I have personal health insurance with the following company. A lack of personal health insurance will not limit your participation on this outreach. ___________________________ Company Name
___________________________ Family Physician
___________________________ Policy Number
___________________________ Physician’s Work Phone
SPIRITUAL HISTORY Salvation Date: (MM/DD/YY) _____________________________________________________________________________________ Describe why you made a decision to follow Christ: __________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________
Describe your church involvement: _______________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________
__________________________________________________________________________________________________ __________________________________________________________________________________________________ Describe your current relationship with God: _______________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________
__________________________________________________________________________________________________ __________________________________________________________________________________________________ Briefly describe why you’d like to be a part of the team: ___________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________
__________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________
RECOMMENDATIONS Please provide the following references: (All references must be at least 21 years old and not related to the applicant.) Pastoral Reference Pastors Name: _______________________________________________________________________________ Church’s Name: _____________________________________________________________________________
Phone: _____________________________________________________________________________ Email: ______________________________________________________________________________ Reference #1 Name: _____________________________________________________________________________ Relation to applicant: _______________________________________________________________ Phone: _____________________________________________________________________________ Email: ______________________________________________________________________________ Reference #2 Name: _____________________________________________________________________________ Relation to applicant: _______________________________________________________________ Phone: _____________________________________________________________________________ Email: ______________________________________________________________________________ Reference #3 Name: _____________________________________________________________________________ Relation to applicant: _______________________________________________________________ Phone: _____________________________________________________________________________ Email: ______________________________________________________________________________
Crossroads Community Cathedral Guatemala Missions Trip Consent and Waiver/Release Form I, ____________________________, understand that participation in the 2018 Guatemala Missions Trip with Crossroads Community Cathedral brings with it a certain element of risk. I understand the inherent risks. Should there be any activity I wish to abstain form, I will notify Crossroads Community Cathedral in writing at the time of application. Release and Indemnification | Parental Travel Consent In consideration of the risks involved, I am under the understanding that both Crossroads Community Cathedral and the Kitchen of Love have taken the necessary precautions to ensure the safety and well-being of each team member. I hereby release and waive any and all claims against Crossroads Community Cathedral, the Kitchen of Love, and its staff arising from my participation in the 2018 Guatemala Missions Trip. In the event of an emergency, I hereby give permission to Crossroads Community Cathedral Missions Trip Leaders to secure proper medical treatment, including hospitalization, anesthesia, surgery, and/or injections of medication. I hereby have given my child permission to travel to the designated country during with provided supervision by Crossroads Community Cathedral through its adults serving as its representatives. __________________________________________ Printed Name
__________________________________________ Signature
__________________________________________ Parent Signature (if under 18)
__________________________________________ Printed Name of Witness
__________________________________________ Signature of Witness
______________________ Date Signed
______________________ Phone Number
______________________ Date Signed
______________________ Date Signed
______________________ Phone Number
