Jesus Centered Ministries, Inc.

Volunteer Information Form

Mission Application

Dates of trip ___________________________________________________________________

Passport name _________________________________________________________________

Address ___________________________________ E-mail _____________________________

City ______________________________________ State __________ Zip code _____________

Preferred name _______________________________________________

Phone#_home___________cell___________

Date of Birth _________________________________________________

Beneficiary for Insurance policy ___________________________________________________

Marital status ____ single ____ married

Gender ____ male _____ female

In case of an emergency, please notify:

Name_________________________________________________________________________

Phone ________________________________ E-mail __________________________________

Church Information

Church affiliation _______________________________________________________________

Present Church membership ______________________________________________________

How many years ______________Church phone number _______________________________

Pastor's name __________________________________________________________________

Languages Proficiency

1) __________________ ___ Beginner ___ Advanced ___Native speaker

2) __________________ ___ Beginner ___ Advanced ___ Native speaker

Name: ________________________________________________________________________

Abilities/talents	Proficiency

1) __________________ ____ Poor ___ Average ___ Above Average

2) __________________ ____ Poor ___ Average ___ Above Average

3) __________________ ____ Poor ___ Average ___ Above Average

My health is: ___ Excellent ___ Good ____ Fair ___ Poor

Are you currently taking any medications? ___ Yes ___ No

If yes, What? ____________________________________________________________________

Do you have any special health needs? ___ Yes ___ No

If yes, please explain

______________________________________________________________________________

I understand and agree that Jesus Centered Ministries, Inc. and any of its missionaries, staff, board members, or other representatives assume no responsibility for loss of property, damage to the same, personal harm, illness, or loss of life, that may occur during the execution of this volunteer mission project; and I, for myself, my heirs, executor, administrators, distributes, and assigns, in consideration of my admission to volunteer service and other good and valuable considerations, do hereby absolve said Jesus Centered Ministries, Inc. and hold them harmless from any claim or demand which I or they might conceivably assert upon the basis of the foregoing. I understand that I will be under the policies of Jesus Centered Ministries and my field supervisor. I agree to abstain from the use of tobacco products, alcoholic beverages, illegal drugs, fraternization and any other behavior that would hinder Christian ministry. I understand that the breach of this contract will be cause for dismissal from the volunteer project and return home at my on expense.

Signature: _____________________________________________________

______________________________________________________________________________

The ________________________________Church of _________________________________

whole-heartedly recommends ____________________________ to Jesus Centered Ministries as sound in his/her faith and spiritually equipped to serve on this volunteer project.

Pastor: _________________________________ Date: ____________________________