Online Application Your Name First Name Last Name Is this application for yourself or a child participant? Myself My child Name (as shown on passport) * First Name Last Name Date of Birth MM DD YYYY Gender Email * Phone Number Mailing Address Address 1 Address 2 City State/Province Zip/Postal Code Country Passport Number Passport Country Passport Expiration MM DD YYYY List your skills, talents or experience which may be helpful on this trip: Prior missions experience (Please list country, organization, dates, and activities) What church do you call home? List any ministries with which you have been active at your church, including the duration of involvement and leadership positions. List any service or leadership activities with which you have been involved outside of church, including the duration of involvement and leadership positions. Please share your salvation experience, and how long you have been a believer. Explain how a person becomes a Christian. If you are not a believer, please describe how your worldview is compatible with our mission in Uganda. Can you agree to support our overall mission even if you do not share our belief system? Why do you want to go on this mission trip? How did you hear about H3? Have you ever been convicted of or pleaded guilty to a criminal offense that would include the sale or use of drugs, child abuse, alcohol consumption, or crime involving actual or attempted sexual misconduct? Yes No If yes to conviction/pleading guilty, please describe the circumstances and offense, and why this should not prevent you from participating in this trip. Emergency Contact Do you agree to these behavior guidelines? I will participate in each training/informational meeting, or make up the meeting I miss with prior permission. I will not be antagonistic to the gospel message as it is shared with our team and our Ugandan counterparts. I will follow and respect the leadership on my project. I will not use bad language, alcohol, drugs or tobacco on the project. I will adhere to the established dress code. I will follow safety precautions during the project. I understand that if I break the terms of this agreement, my leaders may choose to send me home at my own expense. Yes No Do you agree to the statement of risk? I realize and acknowledge that my participation on a mission trip to a foreign country includes risk and possible dangers. I am well aware that my travel to such a foreign country exposes me to such risks as accidents, disease, war, political unrest, injury from construction projects, and other calami- ties. I understand that doing participating in medical work involves risks including exposure to disease, or contracting illness. Yes No Do you agree to the following requirements of participation? I hereby assume any such risks that might result from my participation in any such mission project, and I unconditionally agree to hold H3, its officers, employees, or other agents harm- less for any liability concerning my personal health and wellbeing, or any liability for my personal property that might be lost, damaged, or stolen while on a short-term mission trip. Yes No By typing your name here, you acknowledge that the information on this form is correct to the best of my knowledge. Thank you!
