Chosen Children Ministries

CCM Application Page 1
Chosen Children Ministries
Short-Term Mission Application
PASSPORT Name: _______________________________ Name you go by: _________________________
Passport Number: ________________________________
Full address: ________________________City____________________State______ Zip code___________
Telephone number(s): Home: (_____)______________________ Cell#: (_____)______________________
Church attending: ____________________________ Member? Yes No
T-shirt size: Small Medium Large
XX Large
XXX Large
Email address (please print clearly): ________________________________Occupation: _______________
Do you speak Spanish? Yes No
Date of birth: Month: _______ Day: _____ Year: _______
Emergency Contact: ______________________________________________________________________
Telephone Number
List any medical problems and medications: _________________________________________________
Blood type: _____________________________
Reasons for going on a short-term mission trip:_______________________________________________
Travel Accident Insurance Beneficiary (please complete):
Have you received and read the CCM Guidelines in the team member brochure? Yes No
I, the undersigned, wish to participate in a short-term mission project in Nicaragua conducted under the auspices of Chosen
Children Ministries (“CCM”). By signing this form, I acknowledge (1) that traveling to and in the Country of Nicaragua involves hazards not
customarily encountered when traveling in America. (2) Medical facilities in Nicaragua are substandard and that should a medical emergency
develop during my trip, it is unlikely that I will receive medical care in Nicaragua equivalent to that available in America. (3) Working
conditions in Nicaragua are often inferior to conditions in America. (4) CCM does not carry insurance to insure against any of the risks I may
encounter in Nicaragua.
Despite the foregoing, it is my desire to participate in the work in Nicaragua, and I knowingly assume the risks that are involved and
release CCM, its employees and agents, from any liability for injury, damage, or harm which may occur to my person or property while
traveling in connection with this project or otherwise participating in this project.
I affirm that I am eighteen (18) years of age or older, or the parent/guardian of the participant if under eighteen years of age, and
that this Acknowledgment, Assumption, and Release is binding on me and my executor, administrators, and heirs. I give CCM and its
representative (s) with me on any such trip authority to request and authorize medical and/or hospital treatment for my benefit in the event of
any injury or sickness sustained by me while on such ministry activity, including, without limitation, while traveling to and from any foreign
country. I agree to pay for all such treatment and to reimburse CCM for all costs and expenses incurred by it with respect to such treatment.
________________________________ Date: ____________
Sworn to and subscribed before me
this ________day of ___________, 2010
Signature of Applicant
Notary Public
Signature of Parent or Guardian of Minor Applicant
(If applicable)
My commission expires: _____________
CCM Application Page 2
Chosen Children Ministries
Authorization to Use or Disclose
Protected Health Information
As required by Privacy Regulations, Chosen Children Ministries may not use or disclose your protected health
information without your authorization.
I hereby authorize Chosen Children Ministries and any of its employees to use or disclose the health
information provided to CCM to medical professionals, medical institutions, or CCM short-term mission team
members in Nicaragua or in the US and to act on my behalf in case of a medical emergency.
Health Information authorized to be disclosed includes medications, health conditions, allergies, and all other
health information provided to Chosen Children Ministries.
Effective dates for this authorization: __________________ through _____________ .
Date team departs for Nicaragua
One day after trip return date
This authorization will expire at the end of the above period.
Signature of team member or Authorized Representative (indicate relationship)
Team Name / Church __________________________________
Team Leader