2021 Salt Lake City Mission Project Application
Thank you for your willingness to serve as part of the 2021 Salt Lake City Mission Project. The dates for this year's trip are June 25-July 2, 2021. Cost of trip is $425.
Please complete each section of this application. A completed application does NOT guarantee a place on a team; however, it is the essential first step. If you have any questions, please contact Tim McGhee (tmcghee@fbcpowell.org) or Hunter Long (hunterlong@fbcpowell.org).
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Legal Name *
First and last name
Date of Birth *
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Today's Date *
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Are you a member of First Baptist Powell? *
If you are not a member of FBP, what church are you a member of?
Email *
Parent's Email (if you are under 18 years old)
Phone number *
Address *
HEALTH/MEDICAL INFORMATION
This project will be physically demanding and may require long hours of standing, walking, and lifting. Please complete the following questions.
Do you have any health issues or physical conditions that may limit your physical activity? *
If yes, please explain.
Please list any medications you take regularly (prescription and/or non-prescription).
Do you have any special dietary needs? *
If yes, please explain
Please list any allergies.
Do you require and epi-pen? *
If yes, where do you carry your epi-pen?
MEDICAL INSURANCE
Do you have medical insurance? *
Policy Holder's Name
Policy Number
Group Number
Insurance Company Name and Address
EMERGENCY CONTACT INFORMATION
In case of an emergency, who should we contact?
Name of contact *
Contact's relationship to you *
Contact's phone number *
Contact's email
FINANCIAL RESPONSIBILITY
I authorize First Baptist Powell to purchase an airline ticket for the 2021 Salt Lake City Mission Project on my behalf and by doing so I assume full responsibility of the purchase price of that ticket should I withdraw from the team for any reason. I understand that airline tickets are non-refundable and non-transferable, and I will be responsible for any amount charged for cancellation. I further agree to have the balance owed for the mission trip paid in full by the time of departure.
I have read and agree to the stated financial responsibility. *
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