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5656 SW Humphrey Blvd. Ste 205 | Portland, OR | 97221| T: 503 296 4853 ama@africamissionalliance.org | www.AfricaMissionAlliance.org

TEAM MEMBER APPLICATION FORM Trip you are interested in (See our website for trip dates)___________________________________ General Information NOTE: Please list your name EXACTLY as it is shown on your passport. First ____________________Middle _____________ Last name ______________________Birth date _____ Mailing address______________________________City __________________State _________Zip ______ Male_______ Female________ Email address__________________________________________________ Home phone_________________Work phone_______________Cell________________Marital Status____ Passport number_____________________Expiration date ____________Place issued __________________ (If you do not have a valid passport, the process to get one could take several weeks) Are you a US citizen? __________ If not, list citizenship _________________________________________ How many languages do you speak? (List them) _________________________________________________ Health: Please list any medical problems that you currently have. For example: diabetes, asthma, allergies etc______________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Are you taking medications regularly? ______ If yes, what? _______________________________________ ________________________________________________________________________________________ Please list your current health insurance company and policy number_________________________________ ________________________________________________________________________________________ Please provide two emergency contacts: Emergency contact name__________________________________Address__________________________ ________________________________________________________________________________________ Telephone_____________________________ Emergency contact name__________________________________Address__________________________ ________________________________________________________________________________________ Telephone__________________________ Experience Current Employment _________________________________ Employer_____________________________

Page 1 of 3 Team Member Application

Candidate Initials: ______________


5656 SW Humphrey Blvd. Ste 205 | Portland, OR | 97221| T: 503 296 4853 ama@africamissionalliance.org | www.AfricaMissionAlliance.org

TEAM MEMBER APPLICATION FORM Have you traveled abroad or participated in any short-term mission trip before? ________________________ If yes, where? ____________________________________________________________________________ Have you ever participated on an Africa Mission Alliance Mission team? Yes ___No ___ If yes, when? ____ Areas of Interest (please circle one) □Children □Youth □Leadership Training□ Medical □Computer/Technology □Evangelism □Teacher Training □Business Training □Music□ Handwork (Construction, mechanical, sewing) □Other____________________ Other skills and abilities you expect or hope to use on this team _____________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Do you attend a church? Yes________ No_______ If yes, what church (Name and City) ________________ ________________________________________________________________________________________ References

Please provide the names and details of two character references: Reference 1: Name __________________________________Relationship to you_________________________________ Mailing address______________________________City __________________State _________Zip ______ Email address____________________________________________________________________________ Home phone______________________Work phone___________________Cell_______________________ Reference 2: Name __________________________________Relationship to you________________________________ Mailing address______________________________City __________________State _________Zip ______ Email address____________________________________________________________________________ Home phone______________________Work phone___________________Cell_______________________ I certify that all statements made on the pages of this application, including attachments, are true and accurate, and complete to the best of my knowledge and are made in good faith. I understand that any misleading, inaccurate, or incomplete information may be cause for disqualification or termination. Print Name: ____________________________________________________________________________ Signature of applicant: ___________________________________ Date____________________________

Page 2 of 3 Team Member Application

Candidate Initials: ______________


5656 SW Humphrey Blvd. Ste 205 | Portland, OR | 97221| T: 503 296 4853 ama@africamissionalliance.org | www.AfricaMissionAlliance.org

TEAM MEMBER APPLICATION FORM

Page 3 of 3 Team Member Application

Candidate Initials: ______________

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