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Susquehanna Conference UMVIM Team Roster
Domestic VIM teams will receive supplimental accident insurance once the roster is processed. International teams please submit roster and purchase low cost supplimental insurance from NEJ VIM at
https://www.umvim.org/nej-insurance
.
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* Indicates required question
Email
*
Your email
Sponsoring (Sending) Church and District:
*
Your answer
Team Leader Name:
*
Your answer
I am part of the United Methodist Church listed above.
*
I am a regular attender.
I am a member.
Team Leader Phone Number:
*
Your answer
Is VIM Team Leader VIM Trained?
*
Yes
No
Date of VIM training - if date unknown, list year:
Your answer
Location of Service (city, state)(city, country):
*
Your answer
Name of Organization where you will serve (If applicable):
Your answer
Beginning Trip Date (including travel):
*
MM
/
DD
/
YYYY
End Trip Date (including travel):
*
MM
/
DD
/
YYYY
Total # of Work Days (excluding travel, sightseeing etc.):
*
Choose
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32 or more
Team Members over 35 years old:
Domestic Teams list first & last name
and
full birthdate.
International Teams list first & last name.
*
Your answer
Team Members 18-35 years old:
Domestic Teams list first & last name
and
full birthdate.
International Teams list first & last name.
*
Your answer
Team Members 0-17 years old:
Domestic Teams list first & last name
and
full birthdate.
International Teams list first & last name.
*
Your answer
Supplemental Accident Insurance:
*
We are a domestic journey and will receive insurance through the Susquehanna Conference VIM once this form is submitted.
We are an international journey and we will purchase insurance from NEJ VIM at
https://www.umvim.org/nej-insurance
.
We are an international journey and we have or will purchase other supplemental insurance from another provider.
How many participants are new to missions?
*
Choose
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
More than 30
Select Project Type - Check all that apply:
*
ERT (Early Response Team)
Long Term Recovery
Construction
Medical
Relational/Educational
Other:
Required
Anything else you'd like to add:
Your answer
A copy of your responses will be emailed to the address you provided.
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