TEAM - Short Term Trip Application

Short Term Trip Application

Team
Team Coordinator Information

Person Responsible for Registering Team
Team Coordinator:

First NameLast Name
Team Coordinator Email:
example@example.com
Team Coordinator Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Team Coordinator Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Team Leader Information

Person Responsible for Leading Team on Field
Is the Team Leader the same as Team Coordinator:
Team Leader Name:

First NameLast Name
Team Leader Email:
example@example.com
Team Leader Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Team Leader Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Church/Organization Information
Church/Organization Name:
Church/Organization City/State:

Street Address

Street Address Line 2

CityState

Zip Code
Church/Org Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Church/Org Email:
example@example.com
AG Church District:
If you are not a part of the Assemblies of God, please select Unknown/NA
Church Giving Credit:
Lead Pastor/Director Name:

First NameLast Name
Lead Pastor/Director Email:
example@example.com

Trip Information
Region:
Destination City:
City
Destination Country:
Country
Host Missionary Name:

First NameLast Name
Departure Date:

MonthDayYear
Return Date:

MonthDayYear
Trip Year
Purpose of Trip:
Team Information

Let us know who is on the team. Please include Team Leader and/or Coordinator if also part of the team going.
Team Member Information

Insurance

AGWM Travel Insurance through ACE/Chubb is required by AGWM for all persons traveling abroad to interact with any of our personnel or institutions, etc.
Are there minors going on the trip?
Total Number of Participants:
at $4.95 per person per day; must include the day of departure and the day of return.
Note: Your application specialist will contact you for the insurance payment after receiving your registration forms. If it becomes necessary to adjust travel dates or cancel your trip, please notify your application specialist at least 14 days prior to departure for ACE/Chubb insurance premium adjustments.
I am with AGUSM and hold a U.S. Missions account.
AGUSM Account #:

Confidentiality
I will only use confidential information as it relates to leading missions teams. I will not disclose any of the confidential information made available to me; I will store all Confidential Information in a safe, secure location as long as they are in my possession. I will not use any confidential information for my own self-interest, or for the interest of others, during or after the missions trip. I understand there are missionaries in sensitive countries of the world and I will not do anything to compromise their security.
Signature
Should be Empty:

Short Term Trip Application