Short-Term Mission Team Application (College and High School Students)

ORCHARD KNOB MISSIONARY BAPTIST CHURCH

1734 E. 3RD Street

Chattanooga, Tennessee 37404

Rev. Dr. Rodney T. Morton, Senior Pastor

Mission Trip

Trip Date

Participant's Personal Information

Participant's Legal Name

Participant's Preferred Name

Date of Birth

Age

Country of Birth

Sex at Birth

Address

This address will receive a confirmation email

Primary Phone

Primary Phone Type

Secondary Phone

Secondary Phone Type

Marital Status

Spouse's Name

Frequent Flyer Miles (Airline & #)

Please list any special skills you may possess (fluency in another language, construction skills, medical/dental licensing, etc.)

Attach any licensure applicable for this trip.

Upload (8MB)

While your preferences cannot be guaranteed, they will be considered. Please indicate in what role or in which project you are most interested in participating:

International Trips Only

Do you have a current passport with an expiration date that is more than six months beyond the trip dates?

Passport Application Date

Passport Number

Passport Expiration Date

Name as it appears on Passport

Orchard Knob will purchase traveler’s insurance on your behalf. Please list your beneficiary for this purpose (Name and Relationship)

In Case of Emergency, please notify:

Name

Relationship

Primary Contact Phone 1

Primary Contact Phone 1 Type

Secondary Phone 2

Secondary Phone 2 Type

Health Information

Present State of Health

Are you considered fully vaccinated against COVID-19?

Are you presently under the care of a physician? If yes, please explain.

Are you under any medical restrictions? If yes, please explain.

List all medications prescribed for you that you are taking.

List any allergies that you may have.

Insurance Company:

Policy or Group #:

(attach copy of insurance card)

Upload (8MB)

Address (City, State, ZIP):

Subscriber Name:

Subscriber Number:

Place of Employment:

Subscriber Occupation:

Work Phone

Medical Consent:

In the event of a medical emergency, I hereby give my consent for the team leader or other Orchard Knob Missionary Baptist Church representative to take the steps they deem necessary to procure proper treatment, surgery, medications, and/or anesthetic for me in the event I am unable to grant such permission or my emergency contact person cannot be reached in a timely manner. I further agree to be financially responsible to any such health care provider, and I authorize the release of any medical or insurance related information pertinent to the circumstances. I hereby certify to Orchard Knob Missionary Baptist Church that I have obtained and will maintain in full force and effect during the mission trip adequate primary medical insurance for myself or minor participant.

Acknowledgment and Agreement
By typing my name below and submitting this form, I confirm that the information provided is accurate and complete. I understand that this electronic submission is the legal equivalent of my handwritten signature.
(must be signed by a parent or guardian if under 18 years of age)

Full Name (Typed Signature)

Date

Church Information - ( For High School and College Students only)

Where is your church membership? (if other than Orchard Knob Church)

Do you attend your home church regularly?

If not, where are you attending regularly? Give Pastors name and contact information (phone number, email address)

Is your church prayerfully supporting you in this trip?

List your present ministry involvement and length of time you have served in each area.

Has Orchard Knob ever conducted a background check on you? (Permission is required)

Christian Witness

Are you currently undergoing church discipline?

Have you ever undergone church discipline?

Is your language abusive or profane?

Are you presently experiencing any psychological struggles?

Are you under the care of a mental health professional?

Are you under any kind of significant financial obligation?

Do you have a police record?

Have you ever been convicted in criminal court?

Are you engaging in the use of illegal drugs?

Are you engaging in immoral sexual relations?

Are you involved in homosexual activity?

If you answered yes to any of the above, please explain in this provided section or separate sheet of paper and attach to this document.

Provide attachment (if needed)

Upload (8MB)

Authorization

Notice: This waiver is a document with legal consequences. Read it carefully before signing! Parents must initial with minors and sign for minors at the end of the Church Information - ( For High School and College Students only) section.

I desire to participate in the short-term mission trip identified below, and agree to the following provisions as a condition of my participation:

Early Return. If, at any time, my behavior constitutes a problem on the trip, the team leader has the authority to ask me to return home. Any additional costs incurred as a result of this action (including airfare) will be at my expense. Additionally, should I of my own volition decide to return home early or should changes occur in team travel arrangements that are beyond my control, I agree to bear the financial responsibility for all expenses incurred in my return. I have read and understand the above. (initial here )

Assumption and Release. I agree that situations may arise during this mission trip which may be beyond the control of the leaders or participants. I voluntarily assume all risks related to my own conduct, the conduct of the person, entity, or agents leading the trip, including but not limited to ordinary negligence, lack of supervision, and any product or service defect. I release, forever discharge, and agree not to sue Orchard Knob Missionary Baptist Church, its employees, agents and other participants, and I hereby waive all claims which I may have against the above organization, entities, or persons arising out of or in any connection with my participation in the trip. I have read and understand the above. (initial here)

Travel Advisory. I understand that Orchard Knob Missionary Baptist Church will not sponsor a mission trip to an area for which the United States State Department or similar governmental agency has issued a travel advisory. I understand that Orchard Knob Missionary Baptist Church may accordingly cancel my trip before its departure or call my trip home after it has begun, but before its scheduled conclusion. In either event, I understand that I will likely not receive the full benefit of all of the money I have paid or raised for my trip, and that Orchard Knob Missionary Baptist Church will be unable to refund such moneys. I further agree that if my trip is canceled by Orchard Knob Missionary Baptist Church after it has commenced as result of the issuance of an adverse travel advisory, that I will return to the States or such safer area as requested by Orchard Knob Missionary Baptist Church. I further understand that if I do not leave the restricted travel area when requested to do so, that I will have knowingly assumed the risk of hazardous travel, including without limitation kidnapping, terrorist activity, grave bodily harm (including death), and the risks associated with riots and civil disturbances. I acknowledge that in no event will Orchard Knob Missionary Baptist Church pay a ransom for my return if I am kidnapped or hijacked. I have read and understand the above. (initial here)

Willingness to Shepherd a Minor. (Adults only) I am willing, if needed, to assume oversight and responsibility for a student of my same gender who would like to participate in the mission trip but whose parent cannot accompany them or provide direct oversight at all times. For domestic travel, I would be responsible for supervision during times when genders are separated. For international travel, I understand that I would be responsible for helping the student navigate through the airports, get through customs, make sure the student is where he/she is supposed to be when he/she is supposed to be and on task at all times throughout the trip, and to provide care and even decision-making should the student become ill or have other needs. I understand the student’s legal parents will grant written, temporary permission for me to provide this care. I am willing to assume this OPTIONAL responsibility. (This is optional! initial here)

Minor’s Name:

Photograph & Video Release. I hereby grant permission to the rights of my image, likeness and sound of my voice as recorded on audio or video tape without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I also understand that this material may be used in diverse settings within an unrestricted geographic area. This release applies to all photographic, audio or video recordings collected and may be used for all purposes deemed necessary. Further, I understand that others, with or without the consent of Orchard Knob Missionary Baptist Church may use and/or reproduce such photographs and recordings. By signing this release I understand this permission signifies that photographic or video recordings of me may be electronically displayed via the Internet or in a public setting. I hereby release Orchard Knob Missionary Baptist Church, and any of its associated or affiliated ministries, their elders, directors, officers, agents, employees and members, and appointed advertising agencies, their directors, officers, agents and employees from all claims of every kind on account of such use. There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed. By signing this form I acknowledge that I have completely read and fully understand the above release is irrevocable and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material. (initial here)

Acceptance of Guidelines. I affirm my desire to participate in this short-term mission trip. The information provided by me in this form is truthful. I have read the Orchard Knob Missionary Baptist Church “Mission Team Guidelines” and agree to abide by them. I have read and understand the above. (initial here)

I have carefully read this form and fully understand its contents. I am aware that this is an assumption of liability, a release of liability, and a waiver of claims. I sign this document of my own free will. I have read and understand the above. (initial here)

Furthermore, in submitting this application: I am expressing my agreement with Orchard Knob Missionary Baptist Church’s vision, mission, goal, values and strategy. I am willing to work under the direction of the team leader and to perform any and all assignments with a God-honoring attitude. I am responsible for obtaining all necessary vaccines and medications and consulting with my health care provider about medical concerns. I am confirming that I have the time and energy to devote to the pre-trip responsibilities. I agree to participate in training, preparation meetings and complete all requirements for the trip. I understand that this application will be reviewed by a leadership team and subject to approval. (initial here)

I understand that prayer support is a vital component to the success of any mission so I’m enlisting the prayer support of the following three people:

Prayer Support Person 1

Prayer Support Person 2

Prayer Support Person 3

HIGH SCHOOL AND COLLEGE PARTICIPANTS:

Father’s Phone:

Father’s Email:

Mother’s Phone:

Mother’s Email:

Legal Guardian’s Permission

By typing my name below, I/we give permission for the minor listed below to participate in this short-term mission trip. I/we consent to medical treatment as outlined above and release, discharge, and agree not to sue Orchard Knob Missionary Baptist Church, its employees, agents, or other participants for personal or property damage occurring on or arising out of the mission trip, except for damages caused by gross negligence or intentional misconduct.

Minor’s Name:

Full Name of Parent/Guardian 1 (Typed Signature):

Full Name of Parent/Guardian 2(Typed Signature):

Date

I agree to the statement above

Yes No

I/we also give permission for the minor listed above to be supervised by another consenting adult of the same gender during my absence, including seeking medical care as necessary.

Full Name of Parent/Guardian 1 (Typed Signature):

Full Name of Parent/Guardian 2 (Typed Signature):

Date

I agree to the statement above.

Yes No

Short-Term Mission Team Application (College and High School Students)

Description

Please Fix the Following