Online Mission Application

Online Application

Fill out this form to apply to join us on a short term mission trip
Name (as it appears on your passport)*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Gender*

FemaleMale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Country of Citizenship*
Are you married?*

YesNo
Phone Number*

Area CodePhone Number
E-mail*
Passport Number*
Place Issued:
Date Issued*

MonthDayYear
Expiration Date*

MonthDayYear
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
List List any allergies, medications, or handicaps you have.
Would any of these restrict your participation in the mission trip?

YesNo
Have you been on a mission trip before?*

YesNo
If so, when?

MonthDayYear
If so, where?
If so, with what organization?
What is your pastor's name?*
Pastor's phone number*

Area CodePhone Number
Pastor's E-mail*
Which trip are you applying for?*
Country of destination
What are the dates of this trip?*
mm/dd/yy - mm/dd/yy
What skills do you have that you think will benefit this trip?*
Why do you want to go on this trip?*
We will be purchasing emergency medical and life insurance coverage for you on this trip. Please provide the following:
Beneficiary and relationship to beneficiary:*
Your non-refundable deposit must be paid at the time of your application (refunded only if your application is denied). You may pay by mailing a check to our office, by processing a payment through our PayPal widget, or via credit/debit card on our website.

Your second payment bringing your paid amount to half of the total cost is due three months before your departure date.

Your final payment is due 30 days before departure.
I understand that my application will not be processed until my deposit of $100 is received by Don Shire Ministries.*

I agree to this
Your second payment bringing you to half the balance is due on what date?*

MonthDayYear
Your final payment is due on what date?*

MonthDayYear
Name of person signing this form. (parent must sign for those under 18)*
By checking this box, you signify that you have read and agree to the information provided.*

I agree to this
Enter the message as it's shown*
Should be Empty:

Online Application