Vacation With A Purpose Application

Please answer each question on the form or type NONE if question does not apply to you.

1. Applicant Information

Today's Date *

Trip Applying For *

Full Name *

What is your Middle Name? * Is this your passport name? * YesNo

Home Address *

Phone Number *

E-mail *

Date of Birth *

Sex *

YesNo

Marital Status: *

Occupation *

Place of Employment *

Work Phone *

Cell Phone *

Home Church *

Church Address *

Pastor *

Church Phone *

Denomination or Affiliation *

Choose Your Travel Dates *

What airport will you be flying out of? *

Airport returning to? *

2. Emergency Medical Information

Allergies *

Current Medications *

Doctor *

Doctor's Phone *

Last Tetanus Shot *

Emergency Contact *

Relationship *

Daytime Phone *

Evening Phone *

3. Travel Document Information

Do You Have a Passport? * YesNo

Passport Country *

Passport Expiration Date *

Citizenship *

Country of Birth *

City and State of Birth *

4. Experience & Qualifications

How did you hear about Blessman Ministries, Inc.? *

Have you ever traveled outside of the United States? *

YesNo

Why do you want to go on this trip? *

List any cross-cultural mission experiences you had. Include country, organization and dates. *

List other formal ministry experience you have had. Include organization, responsibility, and dates. *

Do you enjoy working with children? *

YesNo

What skills and/or experience do you have that might be useful on this mission trip? *

Do you have any training/background/certification in any medical profession (i.e. Doctor, Nurse, R.Ph., EMT, PT, ENT, Chiropractor, etc)? *

Will you be raising funds for some or all of your expenses for this trip? *

Yes - all of itYes - part of itNot sureNo - none of it

Describe for us your spiritual condition and/or tell us your faith story. *

Is there any other information that we should know about (felony convictions, legal matters, etc.)? *

Is your name listed on any sex offender registry in the U.S.? *

YesNo

5. Physical Requirements

It is our desire that as many people as possible go on our teams, however, our work can be physically demanding. The experience of a foreign mission trip can be taxing on even the most hardy individuals . To determine whether or not this trip is right for you, please see the list below. If you are still unsure, you may wish to schedule an appointment with our office to discuss your individual situation.

  • Ideally you should be able to walk one half mile over uneven ground surfaces. You also need to be able to manage your own luggage and occasionally help with physical set up of the clinics or building of the homes.
  • If you have any medical conditions, please visit your physician to get his or her blessing to travel with us. Make sure that your physician understands that you will be confined in the airplane for up to 18 hours.
  • Ask your doctor if they recommend anything to prevent blood clots on the flight such as aspirin or exercises in your seat. If you are bringing prescription medications, please make sure you follow all airline guidelines and restrictions for bringing those medications.
  • If there is any question about your health, we may require a medical release from your physician.
  • If you have any psychological conditions, please discuss this with your physician before committing to one of our teams. Please make us aware of any condition, even if it is well controlled.

6. Health Information

Answer Yes or No for each of the following questions.

Are you currently being treated for any sickness or injury? *

YesNo

Are you allergic to any medications? *

YesNo

Do you have any other allergies? *

YesNo

Have you ever had an eating disorder? *

YesNo

Are you required to be on a special diet? *

YesNo

Do you ever sleep walk or have sleeping problems? *

YesNo

Do you get nervous or upset easily? *

YesNo

Have you ever had psychiatric care? *

YesNo

Have you ever been treated for depression? *

YesNo

Do you have any physical disabilities that would keep you from participating in a normal or rigorous activities? *

YesNo

Do you have or have you ever had a seizure disorder? *

YesNo

Do You have or have you ever had asthma or other breathing problems? *

YesNo

Do you have or have you ever had a heart murmur? *

YesNo

Do you have or have you ever had a kidney disease? *

YesNo

Do you have or have you ever had diabetes? *

YesNo

If you answered yes to any of the previous questions, or if you have been diagnosed or treated for any mental or psychological illness or disorder, please give and explanation below. *

7. Self Evaluation

On a scale of 1 - 10, with 10 being the highest, please evaluate yourself in the following areas.

Relating to New People *

Problem Solving *

Organization & Planning *

Confronting *

Leadership *

Receiving Correction *

Finishing What You Start *

Submission to Leaders *

Public or Group Speaking *

Listening *

Encouraging *

Trying New Things *

One-on-One Ministry *

Taking Charge & Giving Directives *

Describe three strengths (not necessarily from the list above) *

Describe three weaknesses (not necessarily from the list above) *

7. Self Evaluation - Continued

Within the past year, have you been involved in any use of tobacco? *

Within the past year have you been involved in any use of alcohol? *

Within the past year have you been involved in any illegal drugs? *

Within the past year have you been involved in any gang-related activities? *

Within the past year have you been involved in a cult of the occult? *

If you answered yes to any, please explain *

8. Final Agreements

The information I have provided is true and complete to the best of my knowledge and I authorize Blessman Ministries, Inc. to verify the authenticity of my statements with the appropriate authorities. I understand that this mission trip could be highly physically and spiritually demanding. In the event that I am accepted to be a participant in this mission trip, I commit to fulfilling the requirements and submit myself under the authority of the trip leaders. I understand that Blessman Ministries, Inc. has taken efforts to ensure each team members' safety on the mission field but also understand that unforeseen events could endanger team members beyond the control of Blessman Ministries, Inc. I will not hold Blessman Ministries, Inc. liable for any accidents, injuries, or illnesses that occur on or due to a mission trip. I understand that at any time I feel uncomfortable with an activity the team is participating that I have the opportunity to decline my involvement. I agree to obtain travel insurance either through Blessman Ministries, Inc.'s provider or on my own. I authorize the trip leaders to seek emergency medical assistance for me as deemed necessary in the event of an emergency. Blessman Ministries, Inc. may perform criminal background checks on applicants.

I agree to this statement and the Trip Policies and Agreements. *