Roca Blanca Missions Application
Foreign Visitor
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Full Name *
Roca Blanca Missions maintains in the strictest of confidence your personal information and will not sell, give, or trade it to anyone.  *Giving your Email is not necessary to participate.  In giving your Email, you consent to receive our monthly online Newsletter.
Email
Address *
Phone Number
Birth Date
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Age
Gender
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Height
Weight
Do you have a passport?
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Passport Number
What is the date of your planned trip?
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Who is your team leader?
Name & relationship of other family members accompanying you on this trip:
In case of emergency contact *
Relationship to you: *
Phone Number: *
Are you able to communicate in Spanish and to what capacity? Check the levels that apply.
What church do you attend?
Church Address
Church Phone Number
Church Pastor
Pastor's E-mail
How long have you attended this Church?
How long have you been a Christian?
How would you rate your physical condition?
Clear selection
Do you have or have you ever had diabetes?
Clear selection
Do you have or have you ever had seizures?
Clear selection
Do you have or have you ever had a heart condition?
Clear selection
Do you have or have you ever had respiratory problems?
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Do you have or have you ever had psychiatric care?
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Do you have a physical disability?
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Are you currently pregnant?
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Do you have or have you ever had motion or altitude sickness?
Clear selection
Please explain any YES answers:
Are you presently under a doctor's care or taking medication?
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If yes, please explain doctor's care or medication below:
Do you have special diet requirements for medical reasons?
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If yes, explain below:
What do you hope to accomplish in Mexico?  Please state your goals or desire that the Lord has put on your heart.
SKILLS INVENTORY & INTERESTS - check all that apply
Please further explain any skills you have:
My Spiritual Gifts are:
I, the undersigned and we, the parents or legal guardians and/or custodians of the undersigned (if a minor), give permission for the undersigned participant to go on a short-term mission project under the leadership of Victory Latin American Outreach (Roca Blanca Missions Base), and HEREBY RELEASE AND AGREE TO HOLD HARMLESS Roca Blanca Missions and their officers, employees, agents, and servants, from any liability whatsoever that might occur to the undersigned, as the result, whether immediate or proximate or not, due to my participation in the short-term mission project sponsored by the above mentioned party.  I specifically agree to personally provide all insurance policy protection that may be necessary, helpful, or desirable for my participation and I will not rely upon Roca Blanca Missions. for such protection.
Participant's Signature: *
Date
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Parent/Guardian (if under 18)
Date
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