ACCMBC Work Team Application Form

1. Applicant Name*

First NameLast Name

2. Date of Birth*

Date

3. Phone Number*

Format: (000) 000-0000.

4. E-mail*

example@example.com

5. Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

6. Home Church*

7. Please list your skills*

8. Do you speak, read or write in any language(s) other than English?*

No, English OnlyYes, Other Languages

9. If you speak, read or write in any language(s) other than English, please list below.

10. Please list your allergies if any

11. Do you have any medical condition(s) that the ACCMBC should be aware of? Enter N/A if there are none.*

12. Are you willing to take the required vaccines as mandated by the government of the country you are traveling to?*

YesNo

13. Have you ever been involved in a lawsuit, charged, found guilty, pleaded guilty or no contest to a criminal charge related to sexual harassment, sexual assault, sexual abuse, physical abuse or child abuse?*

YesNo

13. Are there any facts or circumstances from your past that would call into question you being entrusted with child/youth or vulnerable adult care responsibilities?*

YesNo

14. I agree to immediately disclose any facts or circumstances that may arise in the future that would call into question being entrusted with child/youth and vulnerable adult responsibilities.*

YesNo

I agree to work towards the goals of the team to the best of my ability. I will give my full cooperation to all co-workers and follow the guidelines and direction of the team leader, the ACCMBC and the local missionary base being served. I also understand that the purchase and use of alcohol is forbidden. Romantic relationships with locals or fellow members are also prohibited. Payment or donations to cover trip costs are due prior to the trip and is non-refundable

15. Signature*

Please verify that you are human*