Mission Team Member Application

HPUMC Mission Location
Date (Format: mm/dd/yyyy)
Name (as it appears on passport or ID)*
Preferred Name
Address*
City State Zip*
Phone (home)*
Phone (office)
Phone (cell)
Email*
Date of Birth* (Format: mm/dd/yyyy)
Passport # (if registering for an international trip)*
Passport Expiration Date (if registering for an international trip)*
US or Other (if registering for an international trip)
Church Name
Who do you want to be in a group with:
T-shirt size*




 
Disclaimer: By registering for any HPUMC event/group,
the participant is giving permission for the participant’s photo
to be used in HPUMC publications, print, and online,
unless HPUMC is given written request to the contrary.
 
Do you have allergies to food, drugs, insect bites or stings?*

Explain
Do you have any chronic medical conditions?*

Explain:
Do you take any medications?*

Please list all:
Immunizations and Dates: Tetanus/Diphtheria Booster* (Format: mm/dd/yyyy)
Do you have any physical limitations or disabilities that would affect you in conditions such as extreme heat or cold, high elevation, limited food choices, etc?*

Explain
Blood Type*
In case of emergency, notify:
Emergency Name*
Day Phone*
Evening Phone*
Relationship*
Address*
 
Insurance Company*
Policy & Group #*
Phone*
 
Physician Name*
Physician Phone*
Are you proficient in any foreign language(s)? If so, explain?
Do you have any musical talents? For example, singing or playing guitar.

WAIVER OF RESPONSIBILITY

By submitting the form above, I  volunteer to participate in the mission with Highland Park United Methodist Church, Dallas, Texas. I recognize and accept the inherent risks of domestic and international travel and of mission projects in general.  I hereby voluntarily waive and release the church, its staff, and volunteers of any liability in the event of accident, injury, illness, or mishap.

 
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What is the sum of six and nine?*