Application for Summer International Outreach

Outreach applying for:*

Today's Date:*

MonthDayYear

Full Name:*

First NameLast Name

E-mail:*

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Birthday:*

MonthDayYear

Age

Gender:*

MaleFemale

T-Shirt Size*

(Choose Youth S-M-L or Adult S-M-L-XL)

Emergency Contact*

First NameLast Name

Relationship to you*

Phone Number*

Area CodePhone Number

Emergency Contact E-mail*

Emergency Contact Address (if different from the address above)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

What is your home church's name and address?*

What is the name of your youth leader or pastor? Phone? Email?*

Briefly describe how you came into a relationship with Christ and/or your experience with God*

If applicable, list any Scripture verses God has used to speak to you about being involved in this outreach and anything else you would like us to know about how He has been guiding you.

Missions experience (local or international)

Please list and describe any medical conditions, allergies, dietary restrictions, physical limitations, and/or medications you have that we should be aware of*

Please provide immunization and insurance information.

Immunizations (check all that apply)*

DTAP (Tetanus) current within 10 yearsTyphoid (recommended for Grenada)Hepatitis A (recommended for Grenada)Hepatitis B (recommended for Grenada)

Conditions and transportation in international outreaches can be varied and unpredictable. Are you able to tolerate temperature change, unpredictable conditions, a lot of walking and/or participate in strenuous physical exertion?*

YesNo

Name of Insurance Provider

Insurance Provider Phone Number

Area CodePhone Number

Insurance Policy #

Name of Insured Person

It is required that all participants travelling internationally have Health and Accident Insurance that covers the times and locations of the outreach. You must provide us with the necessary information, as soon as possible. We recommend that you talk with your provider to ensure proper coverage for this outreach.

Passport

If you are applying for an international outreach, please provide passport details.

Full Name as written in your passport

Passport Number

Date of expiry

MonthDayYear

Country:

Team accountability: We at Youth With A Mission want to make your time as exciting and fun as possible. We encourage relationship-building between both guys and gals and it is our desire to create a family atmosphere that we will all enjoy and benefit from. For this reason we DO NOT ALLOW favoritism, pairing off or romantic relationships since these tend to separate the team and put up walls between you and the rest of the group. We want Youth With A Mission to be a place where you can understand the biblical definition of friendship. In signing this agreement, you are willing to put aside any of the above stated relationships so all will have the best possible Youth With A Mission experience.

Giving up rights: On your outreach, you may not be able to live as comfortably as at home. For instance, you may be sleeping on the floor in a sleeping bag. Some people we share with may find jewelry, makeup, certain clothes, rock music (even Christian) etc. offensive. You may be asked to not have some or all of these. Expect a modest dress code.

Your use of electronic devices will also be limited.--WE EXPECT ALL PHONES/DEVICES TO BE LEFT AT HOME (or stored at the base for use at graduation). On Youth With A Mission outreaches you may be involved in visiting people on the streets, in nursing homes, mental hospitals, handicap centers or other sometimes uncomfortable places. In signing this agreement you are stating that you are willing to give up certain “rights” mentioned above if asked to do so, and that you are willing to be in situations that may make you uncomfortable.

We will expect each team member to give your full attention and support to the Youth With A Mission Staff in order to make the outreach a success for all participants.

By typing my name below, I accept and agree to abide by the rules and guidelines of Youth With a Mission, Lebanon, PA

Applicant Name*

Release of Liability
By my name typed below, I/we do hereby release Youth With A Mission, Lebanon, PA., its agents, employees and volunteer assistants from liability whatsoever arising out of any injury, damage or loss which may be sustained by said person during the course of involvements with Youth With A Mission.

Applicant Name*

If under 18 years of age you must have a parent or guardian’s release.

Parent's or Guardian's Signature

Relationship

Date

MonthDayYear

IMPORTANT

Application Deadline: Philadelphia: June 1, 2020

Outreach cost:

Philadelphia: $350, with $40 due with application

Unless full payment has already been made, please be prepared to pay the remaining fees prior to or on arrival at YWAM Lebanon.

Contact Information: Youth With A Mission, PO Box 480, Lebanon, PA 17042

Phone # (717) 274-9010 Fax # (717) 274-9225

Email: ywampa@comcast.net.

Website: www.ywampa.org

I am submitting my fees by the following method:

Check payable to Youth With A MissionCredit card payment (online at www.ywampa/donate/) credit card fees applyOther

Amount

$40 (Philadelphia) to reserve my placeOther

Application for Youth With A Mission Youth Summer Outreach

Church and Missions Experience

Health and Medical

Outreach Guidelines & Consent