Mission Project Application Trip Application for 127 Worldwide Mission Project I have served on a 127 Worldwide mission project within the last 5 years*YesNoI have a 127 Worldwide Managed Missions Account?*YesNoPreferred Mission Project:*Swahiba Networks Kenya (June 18-29)Tumaini Kenya (June 5-17)FBC Longville Kenya (July 15-26)Name* Mr.Ms.Dr.Prof.Rev. Prefix First Last Preferred First Name*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone*Email* Gender*FemaleMaleBirth Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920T-shirt SizeXSSMLXLXXLXXXLAll t-shirts are unisex sizes.Passport InformationDo you have a passport?*Yes, and I am including my information on this applicationYes, but I will add my passport information at a later timeNo, but I have already applied for a passportNo, and I have not yet applied for a passport*Your passport must be valid for 6 months beyond your project date.Name On PassportPassport NumberDate Issued Expiration Date Passport Issuing CountryNationalityEmergency Contact InformationName* First Last RelationshipPhone*Email Health Concerns and/or MedicationsReferencesPlease provide the following information for 3 individuals willing to serve as a reference on your behalf. 127 Worldwide will email a reference form link to the email addresses you provide.Reference 1 Name* First Last Reference 1 Email* Reference 2 Name* First Last Reference 2 Email* Reference 3 Name* First Last Reference 3 Email* Conditions of Volunteer Participation and Release from Liability127 Worldwide’s desire is to build a community of empowered volunteers dedicated to developing into servant leaders both physically and spiritually. As a volunteer, I will cooperate in the fulfillment of 127 Worldwide’s mission. Minors under the age of 16 who plan to travel without a parent or guardian must seek approval from 127 Worldwide staff. Background Certification: I certify that all of the information provided on this application is true and complete. I authorize the 127 Worldwide staff to investigate and verify any and all of the information I have submitted. Because 127 Worldwide strives to provide a safe environment for children and youth, I understand that 127 Worldwide may order a criminal history check, and I authorize this investigation. Volunteer Terms: I agree to abide by 127 Worldwide policies, procedures, and Code of Conduct. I understand 127 Worldwide does not provide any health benefits (i.e. medical, dental, workers compensation, etc.) however limited travel insurance may be provided for me as a volunteer; I understand it is my responsibility to provide this coverage. I understand that 127 Worldwide does not provide volunteer compensation or trade volunteer services for paid mission trips. Property Loss: I understand 127 Worldwide is not responsible for my personal property loss, damaged or stolen while participating in 127 Worldwide volunteer activities. Medical Treatment: I give permission for 127 Worldwide representatives to provide or arrange for emergency care for me, and to arrange for transport to an emergency center for treatment. I consent to medical treatment deemed immediately necessary or advisable by a physician if I am unable to act on my own behalf. I further understand that 127 Worldwide is not responsible for payment for such medical treatment. Photography or Digital Image Permission: I give permission for 127 Worldwide to use, without limitation or obligation, photographs or other media that may include my image or voice to promote or interpret 127 Worldwide programs. Release from Liability: I understand that accidents may occur during my volunteer activities. By signing below, I release the 127 Worldwide, its agents, directors, consultants, and employees from all liability based on any damage, loss, or injury, whether it is the result of ordinary negligence or otherwise, caused to me or my dependent from participation as a volunteer. Consent for Reference Release: I give permission to any person, I provide as a reference to disclose in good faith any information they may have regarding my qualifications to serve on a 127 Worldwide mission project. I will not hold 127 Worldwide and any persons giving references, liable for the exchange of this information. I also waive the right to see references prior to submission to 127 Worldwide. Financial Policies: 127 Worldwide reserves the right to distribute funds in a way that best fulfills the overall goal of the team, meets the needs of the individual team members, and exhibits good stewardship. All monies received for specific trips will be allocated as deemed appropriate by 127 Worldwide. These monies cannot be managed by a volunteer or donor once received. All support raised is designated for a specific trip, not to an individual person. Additionally, any extra money that a team member raises goes to other trip expenses or at the discretion of 127 Worldwide. Acknowledgement and Agreement of Terms*I agree to the terms and conditions listed aboveMission Project Participant Signature*Date* Alumni or Special Application Share this:Click to share on Facebook (Opens in new window)Click to share on Twitter (Opens in new window)Click to share on Google+ (Opens in new window)Click to share on Pinterest (Opens in new window)MoreClick to print (Opens in new window)Click to share on LinkedIn (Opens in new window)Click to share on Tumblr (Opens in new window)Click to share on Reddit (Opens in new window)Click to share on Pocket (Opens in new window)