First-time Applicant?

Are you a member of IPC?

How long have you been a member?

What church do you attend? (name, location, and denomination)

Have you ever been accused or convicted of sexual harassment or child abuse?

Please explain.

Specify language abilities (other than English) and indicate the appropriate level: 

What are your reasons for wanting to participate on a mission project?

List the areas and length of service in which you have served in ministry roles 

(e.g.church, youth ministry, other Christian organizations, etc.)

List your skills or Spiritual gifts which you believe will be useful for a mission trip. 

First Name as shown on passport

Middle Name as shown on passport

Last Name as shown on passport

Suffix as shown on passport

Passport Number

Expiration Date

Gender

Date of Birth (mm/dd/yyyy)

State Issued

Upload a copy of your passport.

Emergency Contact Information #1

Name, Phone, Relationship

Emergency Contact Information #2

Name, Phone, Relationship

Health Insurance Provider

Policy Number

Group Number

Name of the insured

Have you had a tetanus shot in the last 5 years?

Do you have any known allergies, medical problems, or physical limitations?

Please explain.

List any medical restrictions/disabilities

List major medical care you have received in the last 12 months.

List the history of any major illness or surgery. .

What prescription medication are you taking?

How do you want to grow personally as a result of your participation on this trip?

Digital Signature #1

Digital Signature #2

Digital Signature #3