Medical/Dental Mission Trip Application
Acts 1:8 (NIV) "But you will receive power when the Holy Spirit comes on you; and you will be my witnesses in Jerusalem, and in all Judea and Samaria, and to the ends of the earth."Note: This application must be completed in one setting. No ability to be saved.
Open ONLY to Doctor's, NP's, PA's, Dentists Personnel
Thank you all non-medical personnel that were interested in serving on this trip we have reached our Non-Medical Capacity. Thank you all RN/LPN/CNA/ EMTs/ Paramedics we have reach our Capacity.. Blessings, Stella Cathcart (April 27, 2018)
What mission trip are you applying for?
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Please Select
Thailand: October 25-November 3, 2018
Name: Enter your name as it appears on your passport and/or birth certificate.
First Name
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Middle Name
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Last Name
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Suffix
Date of Birth
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Month
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Day
Year
Date Picker Icon
Gender
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Male
Female
Martial Status
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Single
Married
Phone Number
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Area Code
Phone Number
Email Address
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Mailing Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Country of Citizenship
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T-Shirt Size
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Age
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If under 18 years of age, Name of Parent/Guardian
First Name
Last Name
Parent/Guardian Contact Phone Number
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Area Code
Phone Number
Do you have a criminal record?
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Yes
No
If yes, please explain:
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Lifepoint Church Involvement
In order to apply for a Lifepoint mission trip, you MUST be serving, in a lifegroup or tithing at Lifepoint Church.
What campus do you attend at Lifepoint?
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Fredericksburg
Spotsylvania
Stafford
Culpeper
Richmond
King George
What team are you actively serving in?
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Reference 1: Serving Team Leader Name & Email
Required: Upon application submission, you will be sent a reference link. Email the link to your leader and have them fill out the Mission Trip Leader Reference Form.
Are you in a small group?
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Yes
No
Reference 2: Group Leader Name & Email
Required: Upon application submission, you will be sent a reference link. Email the link to your leader and have them fill out the Mission Trip Leader Reference Form.
Do you currently tithe?
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Yes
No
Reference 3: Team Member, Friend, Other Name & Email
Required: Upon application submission, you will be sent a reference link. Email the link to your leader and have them fill out the Mission Trip Leader Reference Form.
Have you served in missions before?
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Yes
No
If yes, list the church/organization and trip location(s):
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Personal Information
Please explain why you want to go on this mission trip:
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Briefly summarize your personal testimony:
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How does your spouse/family feel about your participation in this trip?
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Do you have financial resources to pay for this trip? If not, explain your plan for gathering the needed finances:
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Health Information
Are you pregnant, do you have a physical or mental handicap, disability, or disease that might affect your ability to travel or serve on the mission trip?
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Yes
No
If yes, please explain:
Do you have any chronic illnesses?
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Yes
No
If yes, please explain:
Have you received counseling or therapy in the past two years?
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Yes
No
If yes, please explain:
Are you currently on medication prescribed by a doctor?
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Yes
No
If yes, please explain:
Please list any medication or food allergies you may have:
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Medical/Dental Professional
Employer:
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Employer's Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your profession?
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What is your specialty?
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Are you flexible to work in a different part of your profession other than your specialty?
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Yes
No
How many years of experience do you have in your profession?
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Are you currently working in your profession?
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Yes
No
Are your currently license in your profession?
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Yes
No
Medical License Number:
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State of Issue:
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If necessary, are you able to function in an unsterile environment, such as working in a village or in a hut?
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Yes
No
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Signature & Upload Picture Here
I am committing to the following:
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Attend and participate in team meetings
If selected on the team to pay in full or complete fundraising
Honor the empowered team leaders
Respond to emails, phone calls or messages from team leaders
By digitally signing below, I indicate that all information given on this application is accurate and complete, to the best of my knowledge. Late applications will not be accepted for any reason.
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Upload Photo Here
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Submit
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