Mission Builder Institute for the Nations Youth With A Mission – Sunshine Coast Mission Builders Application Form Page 1 PART 1- Personal Details You are Applying for: MISSION BUILDER Start Date: Month Please select... January February March April May June July August September October November December Year End Date: Month Please select... January February March April May June July August September October November December 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: Email Emergency Contact (Who do we need to contact in case of an emergency) Name: Phone: Address: Relationship: Birth Details Date Please select... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month Please select... January February March April May June July August September October November December Year Citizenship Passport Details Passport Number Place of Issue Expiry Date Languages spoken How well do you speak English? Please select... Bad 1 2 3 4 5 6 7 8 9 10 Good Marital StatusPlease select... Single Married Divorced Engaged Remarried Widowed Spouse’s name (if applicable) Children’s Details Names, birth details, passport details, citizenship (attach extra page if necessary) Page 2 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 Page 3 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 LiabilityI do hereby release Youth With A Mission INC, its agents, employees and volunteer assistants from any liabilitywhatsoever arising out of any injury, damage or loss which may be sustained by said person during the course ofinvolvement with Youth With A Mission. Signed: Date: Consent for TreatmentI hereby agree to the performance of such treatment, anaesthetics and operations as in the opinion of the attendingphysician if deemed necessary on. Signed: Date: Consent for BurialI agree that, in the case of my death while with Youth With A Mission, Youth With A Mission may carryout the burial in the place of the deceased. If my family desires to have my body shipped home, myfamily will pay for it. I hereby absolve Youth With A Mission and all its staff and associates of any burialcosts. Signed: Date: Youth With A Mission Sunshine CoastPO BOX 5633 MAROOCHYDORE QLD 4558 AUSTRALIAPhone: (07) 5479 0580 Fax: (07) 5479 0380 Email: firstname.lastname@example.org Web page: www.ywamwaves.com Need assistance with this form?