Mission Builder Apply

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PART 1- Personal Details

You are Applying for: MISSION BUILDER

Start Date: Month

Year

End Date: Month

Year

Name: (write your name as found in passport)

Last Name

First Name

Middle Name

Permanent Address: Street

City

State/Province

Post Zip Country

Country

Current Address (if different from above)

Contact Info

Home Phone

Work Phone:

Fax number:

Emergency Contact (Who do we need to contact in case of an emergency)

Name:

Phone:

Address:

Relationship:

Birth Details

Date

Month

Year

Citizenship

Passport Details

Passport Number

Place of Issue

Expiry Date

Languages spoken

How well do you speak English?

Marital Status

Spouse’s name (if applicable)

Children’s Details Names, birth details, passport details, citizenship (attach extra page if necessary)

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Part 1- Personal Details (continued)

Why do you want to Mission Build and what do you hope to learn from this experience?

Have you ever beenconvicted of a crime? (if yes, explain)

Skills or Talents

Have you ever done a DTS with YWAM previously? If yes, where and when?

What do you feel you will contribute to our community while mission building?

Medical History

Please answer all questions. Comment on all positive answers at the end of this form or on a separate sheet.

Have you ever had any of the following?

Skin conditions

YESNO

Shortness of breath

YESNO

Stomach/Duodenal Ulcer

YESNO

Eye trouble

YESNO

Hay Fever

YESNO

Gall bladder problems

YESNO

Ear trouble

YESNO

Asthma

YESNO

Jaundice

YESNO

Head injury

YESNO

High blood pressure

YESNO

Intestinal troubles

YESNO

Recurrent headaches

YESNO

Low blood pressure

YESNO

Recurrent diarrhea

YESNO

Epilepsy

YESNO

Heart trouble

YESNO

Chronic constipation

YESNO

Fainting spells

YESNO

Rheumatism/Arthritis

YESNO

Diabetes

YESNO

Weakness

YESNO

Back problems

YESNO

Kidney Disease

YESNO

Paralysis

YESNO

Dislocation of joints

YESNO

Anemia

YESNO

Insomnia

YESNO

Broken bones

YESNO

Venereal Disease

YESNO

Mental/nervous disorders

YESNO

Anorexia/Bulimia

YESNO

Tumor/Cancer

YESNO

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Have you ever had any of the following?

Allergy

Penicillin

YESNO

Sulphonamides

YESNO

Serum

YESNO

Foods

YESNO

Specify

Any Other

YESNO

Specify

Surgery

Appendectomy

YESNO

Tonsillectomy

YESNO

Hernia repair

YESNO

Other

YESNO

Specify

Females Only

Irregular periods

YESNO

Severe cramps

YESNO

Excessive flow

YESNO

Are you pregnant?

YESNO

Are you at present under a Doctor's care for any condition?

YESNO

Are you taking any medication at this time?

YESNO

Please provide details of any positive answers and give details of any other illnesses you have had.

Haveyou ever had any of the following Communicable Diseases?

Chicken PoxScarlet FeverMeasles (Rubella)TuberculosisMeasles (Rubella)HepatitisMumpsAIDS/HIVPertussis

Part Two– Release of Liability & Other Declarationslick here to enter a heading

Release of Liability

I do hereby release Youth With A Mission INC, its agents, employees and volunteer assistants from any liability
whatsoever arising out of any injury, damage or loss which may be sustained by said person during the course of
involvement with Youth With A Mission.

Signed:

Date:

Consent for Treatment

I hereby agree to the performance of such treatment, anaesthetics and operations as in the opinion of the attending
physician if deemed necessary on.

Signed:

Date:

Consent for Burial

I agree that, in the case of my death while with Youth With A Mission, Youth With A Mission may carry
out the burial in the place of the deceased. If my family desires to have my body shipped home, my
family will pay for it. I hereby absolve Youth With A Mission and all its staff and associates of any burial
costs.

Signed:

Date:

Youth With A Mission Sunshine Coast
PO BOX 5633 MAROOCHYDORE QLD 4558 AUSTRALIA
Phone: (07) 5479 0580 Fax: (07) 5479 0380 Email: admin@ywamwaves.com Web page: www.ywamwaves.com

Institute for the Nations Youth With A Mission – Sunshine Coast Mission Builders Application Form

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Part Two– Release of Liability & Other Declarationslick here to enter a heading

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