Disaster Relief Application

Disaster Relief Application
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age Requirements:

12-15 must be accompanied by an adult

16-18 must be accompanied by a shaperone
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Occupation*
Marital Status*

SingleMarriedDivorced
Name of Spouse if Married
Emergency Contact (someone that is not on the trip with you)*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
T-Shirt Size*

Youth SmallYouth MediumYouth LargeYouth X LargeUnisex SmallUnisex MediumUnisex LargeUnisex X LargeUnisex 2X LargeUnisex 3X Large
I have t-shirts from previous Compassion In Action trips*

None12345
Do you carry Thrivent insurance?*

YesNo
If yes, are you willing to use your $250 Thrivent Action Team benefit for supplies for this outreach?

YesNo
If your are willing to apply for those Action Team benefits, how many do you have available for this year?

123456
Do you attend church and if so how often?*

I do not attend a churchI attend weeklyI attend monthlyI attend occasionally
If you attend a church what is the name of the church and in what city?*
Describe your relationship with Jesus:*
Why are you applying to go on this disaster relief trip?*
Date of Disaster Relief Trip*

MonthDayYear
Date
Location of Disaster Relief Trip*
Have you attended a mission trip or disaster relief trip with Compassion In Action in the past?*

YesNo
If this is your first mission or disaster relief trip with Compassion In Action?*

YesNo
Compassion In Action requires a letter of reference from your pastor or employer if you answered yes to the above question. Please provide the full name, phone number and email of your pastor or employer.

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Have you ever been charged, convicted, or pled guilty to a crime?*

YesNo
If yes, please explain:
Do you struggle with motion sickness?*

YesNo
Are you able to sit in a second or third row van seat without getting sick?*

YesNo
Are you under the care of a Dr for a current medical condition?*

YesNo
If yes, please explain including treatment.
Are you on any prescription medications, (include indications)?*
I understand that Compassion In Action is encouraging me to be up to date on my tetanus shot?*

YesNo
Are you diabetic?*

YesNo
Are you being treated with:*

Oral medInsulinNone
Have you ever had suicidal thoughts or attempted to take your life?*

YesNo
If yes, please explain.
Are you a recovering addict?*

YesNo
If yes, please describe your journey and how long you have been sober?
Are you able to walk at least one mile on rugged terrain?*

YesNo
Are you able to lift 25 pounds of debris?*

YesNo
Are you a worship leader?*

YesNo
Do you play guitar?*

YesNo
Do you have a van or SUV available to transport team members and are you willing to drive?*

YesNo
If you answered yes, please clarify SUV or van and seating capacity
Do you have any of the following to bring on the trip:*

Mini excavatorCovered tool trailerSkid steerFour wheeler with trailer to haul itGeneratorChainsawNone of the above
If you own a chainsaw and willing to bring it are you experienced?*

YesNo
How would you rate your ability to be flexible?*
How well do you take instructions from others?*
How would you rate your ability to be gracious to those with differing beliefs?*
Trip Fee: Option 1-$350 with travel/loding, Option 2-$200 to meet at the ministry site.

Option 1 includes: Compassion T-shirts, transportation, gas, hotel for two nights, food and lodging on ministry site.

Option 2 includes: Compassion T-Shirts, food and lodging on ministry site.

Not included: Meals on travel days

Fees are non-refundable, but are transferable for the same sex (lodging issue)

Application closes 2 weeks prior to the trip
Will you be traveling with the team or meet at the ministry site*

Option 1-Traveling with the team for $350Option 2-Meet at the ministry site for $200
Payment Options:*

Check or Money Order to: Compassion In Action, 111785 Turtle Ridge Rd, Marshfield, WI 54449Paypal or Credit Cards (scan QR code below) OR go to www.mycompassion.info
Serving God through missions and disaster relief can be exhilerating, yet challenging at times. With many opportunities that we get to face through our travels, it can be strenuous and sometimes stressful. Here are a few examples:

1-Long van, bus or truck rides on bumpy, dirty, winding, hilly roads.

2-We work long hard days, but it is nothing compared to the devastation those we will be serving are facing.

3-Rest rooms are not always readily accessible or at the same standards that we are accustomed to.

4-Disaster relief trips vary greatly compared to mission trips because there is so much uncertainty about many things. Concerning food, we have never gone hungry, but we have eaten MRE's at the job site, peanut butter sandwiches, Red Cross meals, local people driving around on 4wheelers handing out sandwiches, etc. If you have a special diet or food allergies this trip probably isn't for you.

5-There will be dangerous debris, nails, sharp metal, broken glass, and yes even rodents and reptiles at times to include snakes.

6-The lodging will be dorm style once we arrive, divided by male and female.

7-During travel days you may have to sleep in the same bed as another person of the same sex.

8-Heating and/or air conditioning may not be available.

9-We will trust God for electricity, but we have been on a trip where the power went out for an extended period of time.

10-Smells of rotting food, debris, dead animals, mold and sewage are prevalent on diaster relief sites.

11-There can be a considerable amount of walking involved on the trip, as well as climbing hills and/or several flights of stairs.

12-The weather may vary from very hot or very cold with poor air quality.

13-You can be assured that we will always have safe water for our team.

14-Local medical hospitals have often been either compromised or overflowing from the disaster. If you have serious medical conditions this trip is probably not best for you.

All of these factors may aggravate certain health conditions, including physical and mental health. Medical facilities often provide inadequate care, compared to our standards. If you struggle with substantial physical limitations, moderate anxiety or mental health challenges, this trip is not advised due to challenging and ever changing conditions.
Compassion In Action Inc
Liability Release and Applicant Agreement

As a volunteer serving with Compassion In Action Inc, I understand that there are certain risks of injury involved in this type of trip. In light of the risks involved, I still choose to take part in this project.
I hereby release Compassion In Action Inc and its agents, and volunteer assistants from any liability whatsoever arising out of any injury, damage, or loss which may be sustained by said person(s) during the course of involvement with Compassion In Action.
I agree to the following:*

I understand that Compassion In Action Inc. and all of it's officers will not be held liable for any accident, injury or death.I give Compassion In Action Inc, permission to use videos and pictures of me.I understand that if I am a danger to myself or others I will return home ahead of schedule at my expense.I will not consume alcohol during the disaster relief trip to include all/any locations. I understand that if I violate this policy, I will be exempt from attending any future trips with Compassion In Action.I will not possess or use illegal drugs. I understand that if I violate this policy I will return home ahead of schedule at my expense.I agree to abide by the dress code: ministry time-Compassion t-shirts with pants or capris, and leisure time-no thong swim suits, modest swim suits and modest attire.I understand that this is a faith-based outreach.I understand that all funds are non-refundable.I have read this Liability Release and Agreement and understand the contents.I fully understand that this is a waiver and release of liability.
Signature of Minor Child

Clear
Signature*

Clear
Date*

MonthDayYear
Date
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