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Dash for Degeance
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Dash for Degeance!
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Short-term Mission Application
Short-term Mission Application
Your Full Name (as on Passport)
Date of Trip
Apt, Suite, Bldg. (optional)
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
East Timor (Timor Timur)
Papua New Guinea
Saint Kitts and Nevis
Sao Tome and Principe
Trinidad and Tobago
United Arab Emirates
United States of America
Weight in Pounds
Do you know Jesus as your personal savior?
Emergency Contact Information
Name, Phone, Email, Address
I can speak...
Do you have any physical of health conditions that may limit you ability to perform ministry on this trip (sensitivity to heat, semi-strenuous hiking, etc)? If yes, please explain.
Prescription drugs you are currently taking?
Dietary restrictions or needs?
Please list any skills or talents you have that may be useful on this mission trip.
Are you currently, or in the last year have you been, under a doctor's care (including psychiatric/psychological)? If yes, please explain.
Have you had any emotional problems that would be aggravated by the increased stress of being on a cross-cultural mission (depression, anxiety, etc)? If yes, please explain.
If you sponsor a child with Mission Possible, please provide his/her ID number.
I am aware that basic, short term trip insurance is provided for persons participating in the program. It is my responsibility to review the policy details and ensure this level of protection meets my needs. If additional protection is needed, I agree that it is my responsibility to engage an insurance provider for such protection.
I am aware of and agree with Mission Possible’s policy to refuse to pay ransom or make other concessions to kidnappers or terrorists, believing such actions would encourage more hostage-takings. I understand Mission Possible discourages private individuals or companies from paying ransom to free a hostage.
I have read the Team Member Guide and agree to abide with the Short-Term Team Agreement, dress code and other rules of Mission Possible. I understand that no smoking, alcohol or illegal drugs are allowed on this trip.
Foreign travel by its very nature offers an unfamiliar and unique environment and risks of injury or death to both persons and property are inherent. I understand that travel to Haiti or the Dominican Republic involves greater health and safety risks than general international travel.
“Risks” include, but are not limited to, the following: physical injury or property damage related to traveling by plane, bus, train, car, truck, van, or any other vehicle; other general risks to person or property associated with travel; encountering or experiencing sickness, illness, disease, accident, injury or damage to participant’s person or personal property, or even death; Loss or destruction of participant’s personal property; exposure to emotionally disturbing conditions; exposure to harsh, extreme, or substandard conditions; crime; any and all inherent risks with international travel including, but not limited to: political instability, rioting, kidnapping, natural disasters, lack of electricity, lack of running water, or lack of sanitary sewage control; harsh sleeping conditions; evacuation from the activity location; mosquito-borne diseases including, but not limited to malaria, zika, chikungunya, and dengue fever; and lack of access to medical care.
Emergency medical care and facilities are limited and access to emergency medical care may not be readily available. I understand that by my participation with Mission Possible, I am acknowledging and accepting these risks and circumstances. I consent to and authorize Mission Possible to obtain reasonably necessary medical treatment for me in the event of an emergency.
I agree that should it be necessary for me to return home due to medical reasons, disciplinary actions, or otherwise, I hereby assume all transportation costs involved.
In consideration of my being accepted for participation in the program, I hereby, to the fullest extent permitted by law, voluntarily, fully, unconditionally, and without reserve release and agree to hold harmless and indemnify Mission Possible and each of its employees, directors, officers, agents, and volunteers from and against any and all liability, claims, demands, actions, damages, expenses, and costs, including attorney’s fees, loss of judgments of whatsoever kind and nature which may result from or arise out of the participation by myself or my child, whether or not resulting in whole or in part from my or my child’s negligence, acts, or omissions or from the negligence, acts, or omissions of Mission Possible or its employees, directors, officers, agents, or volunteers.
My online submission here indicates that I have, to my full satisfaction, obtained all information necessary for me to assess the risks of foreign travel and that I am willingly assuming these risks for myself and/or my minor child.
By submitting this application, I affirm that the information in this application is true.
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