General Information

Last Name
First Name
Choose one trip to apply for: ---Asian Infusion 2012East Asia + Hong KongEast Asia + PhilippinesThailandEast AsiaEast Asia + Hong Kong
DOB
Address
City
State
Zip
Email
Home Phone
Cell Phone
Profession
Church Staff? (Y/N)
US Citizen? (Y/N)
Passport #
Expiration Date
Country of Passport
Visa Status

Spiritual Background

Briefly tell how you became a Christian

What is the name of your local church? How long have you been a member?

Describe briefly why you want to be part of a short term mission trip and how you hope to use your cross-cultural experience when you return?

Have you had any previous experience sharing the gospel with strangers? Explain.

What contact have you had with racial, ethnic or cultural groups other than your own?

What are your strengths in a team-based setting?

What are your weaknesses in a team-based setting?

Experience

Past missions trip location/Date
Past missions trip location/Date
Past missions trip location/Date

Small group member? (Y/N)
Small group leader? (Y/N)

Overseas Travel? (Y/N)
Locations

Skills

Accounting
Administration
Video
Evangelism
Drama
Graphics
Computer
Photography
Sports
Writing
Musical Instrument
Instrument:
Vocalist
Language
Fluency (1=Beg / 2=Int / 3=Adv)

Medical Information

(please be accurate and specific)

List Major Illnesses in last 12 months
List any Allergies
Blood Type
List any (prescription) medications you would bring with you
List Physical limitations/Restrictions
Have you had Treatment / Hospitalizations for an emotional or mental condition in last 5 years? (Y/N) If “Yes,” please describe
Date of last Tetanus Booster
Date of Hepatitis A Vaccine
Date of Hepatitis B Vaccine
Insured? (Y/N)
Insurance Company
Policy #
Insurance Contacted? (Y/N)

Emergency Contact Information

Contact Name
Contact Address
Contact City
Contact State
Contact Zip
Contact Home Phone
Contact Work Phone
Contact Mobile Phone
Contact Email
Contact Relation

References

Please give the name, address and telephone number of three references. (One from your pastor, and the other two from family or close friends)

Pastor

Pastor’s Name
Street Address
City
State
Zip
Email
Home Phone
Work Phone
Cell Phone

Reference 2

Name
Street Address
City
State
Zip
Email
Home Phone
Work Phone
Cell Phone

Reference 3

Name
Street Address
City
State
Zip
Email
Home Phone
Work Phone
Cell Phone

1) Overseas missions are dependent upon the teams serving in a united manner both together and with the receiving church/ministry. While there are needs requiring appeal of direction or action, the witness of the team (as seen in John 13:34-35) is as important to the effectiveness of the mission as the labor itself. Following leadership is a key component of that unity. Below is a declaration of your commitment to Biblical submission: I understand the importance of following the leadership of both my team leader and any in-country leaders for this mission trip. I am committed to submitting to their Biblical leadership and following all team
directives.

I Accept

2) This mission trip will undertake a project to eternally benefit the people of the city and country where your team will serve. While the project may focus on any number of different objectives, it will be imperative that each team member dedicate themselves to the equipping, roles, and on-site efforts with full dedication. As such, an agreement of mission commitment is given here: I recognize that the mission project on which I serve has significant spiritual implications. Therefore, I commit to engage fully in all equipping times and material, in whatever role I am asked to play and in the itinerary of activities for our mission team while on-site.

I Accept

3) We in e3 Leadership Group are excited about the work God is doing overseas, and encouraged by people who are willing to go and serve those of other nations. e3LG takes very seriously the responsibility for the care and protection of each short term team (STM) member during the time of the scheduled trip. However, if an STM team member chooses to extend his/her time of travel, or to engage in activities outside the scope of the STM, either before,
during, or after the scheduled STM trip, then e3LG will not be responsible for those expanded travels or activities. The following is given as your statement of release from liability: I release e3LG, all of its agents and other persons and/or organizations, from any and all liability that may result from travel and/or activities beyond or outside the scope of the scheduled STM trip.

I Accept

Please give or send the referral form to your references.

Please return completed application to e3 Leadership Group at info@e3leadershipgroup.net (as a Word e-mail attachment) or to the address below. Please include the $15 non-refundable application fee (payable to e3 Leadership Group).

If you have any questions regarding this application or the trip, please contact ChingYu Wang, STM coordinator, 816-308-9988.