Please

enclose 2
passport
sized
MISSION DIRECT photos
SHORT TERM MISSION TRIP APPLICATION FORM
Please print clearly (in black)
We appreciate that if you have previously been on a trip with us you will have supplied much of this information before;
however we would request that you complete this in full in order for us to maintain accurate records. Please do not hesitate to
call us with any queries or questions concerning this form or the trip on (01582) 720056.

APPLICANT PERSONAL DETAILS

First Name(s)
Surname Title
(As on Passport)
Preferred name for name badge
Marital status
(James = Jim)

Address

Postcode

Home phone Work phone Mobile

Email Address

Please tick if you do not want us to share your email address with other team members □

Male /Female Age Date of Birth

Occupation Citizenship

Have you travelled with Mission Direct before? If yes when and where?

How did you hear of Mission Direct?

TRIP DETAILS – Which trip are you applying for?

Country Have you been to this country before?

Preferred dates Alternative dates

PASSPORT DETAILS

Passport Number Place of Issue

Date of Issue Place of Birth

NOTE:- YOUR PASSPORT MUST HAVE 6 MONTHS

Expiry Date
VALIDITY AFTER RETURN TRAVEL DATE

For Office Use Only Rec’d Deposit Complete Contact

Mission Trip Application Form 07 Version 1

CHURCH LEADER REFERENCE
If you regularly attend a church please ask your church leader to complete this section and get him/her to sign where
indicated. If you do not regularly attend a church please leave blank.
Name Phone Number

Church Name E-mail

Address

Postcode

Comments

I approve this application. Signed Date

EMERGENCY CONTACT DETAILS

This person may give consent for medical treatment if I am unable to do so
Name Relationship

Home phone Work phone Mobile

E-mail

Address

Postcode

Mission Direct is unusual in that you do not have to be skilled to come. However, it helps us to know if you are
skilled or gifted in certain areas. Please could you let us know any skills you have e.g. overseas experience,
photography, leading worship, accounting, writing, construction, welding, DIY, electrical etc;
(please add additional paper if necessary)

SPECIAL REQUIREMENTS
Please give details below of any special requirements regarding dietary needs, accommodation, flight seats etc.

T-shirt size
S M L XL XXL
(Please circle)

Mission Trip Application Form 07 Version 1

MISSION DIRECT MEDICAL INFORMATION

PRINT NAME

Your medical information is an important part of the application. We do not determine your physical or emotional
preparedness to serve. This is your responsibility and you must consult with your doctor to determine your
readiness and make arrangements for your health and physical requirements without relying on any action before,
during or after the time of service with Mission Direct or anyone connected with them. In certain circumstances,
Mission Direct may also ask you to provide a consent letter from your doctor before accepting your application.

Travel & medical insurance which includes the cost of medical treatment and emergency airlift is required for each
participant of a Mission Direct team and is included in your contributions.

Any pre-existing conditions will need to be assessed before insurance cover is issued.

Do you suffer from any of the following? Please tick the ‘yes’ or ‘no’ box as appropriate:

Yes No Yes No
Anaemia Fainting / Blackouts / Dizziness
Arthritis Frequent infections
Asthma Heart Disease / Angina
Back Strain / Pain / Problems Hepatitis / Jaundice / Liver Problems
Blood Clotting or Bleeding Disorder High or Low Blood Pressure
Cancer / Recent Chemotherapy Kidney Problems / Stones
Chronic or Excessive Fatigue Severe or Migraine Headaches
Depression / Sleep Disorder Shortness of Breath
Diabetes (Type 1 or 2) Stomach or Duodenal Ulcer
Emotional/Mental/Nervous Breakdown or
Stroke
Disorders
Epilepsy / Seizures Vision loss not corrected by glasses
Have you had any surgery within the last six Have you had a baby within the last
months? six months?
Have you ever had an injury or health problem Have you ever had any significant
that has substantially limited or restricted your illness or injury other than those
lifestyle or work capacity? already noted?
Do you require the use of any braces,
Any medical condition that is currently, or has in
prosthesis, supportive devices or aid
the last 5 years been treated by a physician,
to do your job or activities of daily
chiropractor or healer?
living?
Ladies only – Are you pregnant?
Any other relevant medical factors?

If you have answered ‘Yes’ to any of the above questions or you are currently under the care of a doctor, please
give full details here or on a separate sheet and attach to this page.

Mission Trip Application Form 07 Version 1

MISSION DIRECT MEDICAL INFORMATION (Continued)
Please list all known food and drug allergies.

Please state any dietary requirements e.g. Vegetarian, Nut/Spices/Wheat intolerance etc.

Please list all medication you are currently taking.

Name Dosage Frequency

DECLARATION

1) I confirm I will have adequate supplies of medication(s) for the duration of my trip.

(Please circle) YES NO N/A

2) I confirm this is an accurate account of my State of Health.

Signature Date

MISSION DIRECT

Mission Trip Application Form 07 Version 1

Mission Direct projects are in developing countries. Such locations may have access only to unconventional
modes of transportation, communication and accommodation. Team participants may experience inconveniences
resulting from international travel, illness, and cultural differences. Because of the trip’s nature, Mission Direct
asks that each participant understand and execute the following liability release and indemnity.

RELEASE OF LIABILITY AND INDEMNITY

I and all members of my family, accept the risks and responsibilities associated with my Mission Direct trip. I
hereby agree to release Mission Direct, their directors, officers, agents, members, employees, representatives,
successors and assignees from any and all claims, liability, loss, expense, costs and proceedings in respect of
personal injury or illness or property that might arise from my outreach with Mission Direct. I understand that
travelling to and from the location that I am working in, is my responsibility and Mission Direct shall not be liable
for any accidents, sickness or injuries during this travel or on location with the Mission Direct programme. I agree
to indemnify Mission Direct from and against any such claims, liability, loss, expense, costs and proceedings.

If I require any medical attention I understand that Mission Direct is not responsible for treatment. If however,
Mission Direct staff, decide to render aid, I give permission for whatever treatment is deemed medically necessary
by Mission Direct staff whether at a local clinic, or other location. The laws of England and Wales shall govern this
release of liability and indemnity. I have read, understood and agreed with all of the above.

PARTICIPANT (PRINT NAME)

Signature Date

WITNESS (PRINT NAME)

Witness address

Postcode

Witness signature Date

GIFT AID DECLARATION

We can now claim back tax against all your donations since 6 April 2000; provided you are a UK taxpayer. If you
would like to make your donations worth more – at no cost to you – please complete the details below. For this
Gift Aid Declaration to be valid, you must pay at least as much UK tax as the amount claimed. If your
circumstances change please inform us.

Name

Address

Postcode

Signature Date

Mission Direct is a Company Limited by Guarantee No. 5289161 – Registered Charity No. 1107824.
Website: www.missiondirect.org Address: Mission Direct, 6B Britannia House, Leagrave Road, Luton, LU3 1RJ.
Tel: (01582) 720056. Fax: (01582) 720144 E-mail: info@missiondirect.org .

PLEASE SEND THIS FORM WITH YOUR £100 DEPOSIT TO THE ABOVE ADDRESS. PLEASE MAKE CHEQUES PAYABLE TO MISSION
DIRECT.

Mission Trip Application Form 07 Version 1