INDV/FAM - Short Term Trip Application

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

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 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