Please answer all applicable information (type or print). All information will be confidential and will only be shared with appropriate personnel. Use separate sheets as necessary.

Full Name (as on Passport) ____________________________ Male____Female_____

Birth Date (day/mo/year) ____ /____ /____ /

Home Address __________________________________________________________

City/Town _____________________________ State _____ Zip Code ____________

Phone ( _____)________________ E-mail___________________________________

Your Citizenship: USA ______ Other _______________________________________

Do you have a valid passport? Yes ____ No ____ Applied for-Date_ _______________

Passport Number ___________________ Issued at_ ____________________________

Please enclose two photos. Attached: Yes _____

Marital Status: Married ___ Single ___ Divorced ___ Widowed ___ Re-married ____

Spouse's Name if applicable _______________________________________________

Emergency contact(s)
(Name, address, phone number, relationship): _______________________________________________________________________
_______________________________________________________________________

Medical History
a. Your Health: Excellent ____ Good ____ Fair ____ Poor ____ Other ____

b. Please list limitations ________________________________________________

c. Any history of the following (circle): trick knee, week ankles, bad back,
other ____________________________________________________________

d. Are you subject to (circle): diabetes, epilepsy, heart disease, hypertension,
other _____________________________________________________________

e. Appendix removed? ________________

f. Tetanus shot updated? _______________

g. List Current Medications: ____________________________________________ _________________________________________________________________

h. Allergies (food, drug, other) __________________________________________ _________________________________________________________________

i. Medical treatment received in past 12 months:____________________________ _________________________________________________________________

j. Have you had or been exposed to any contagious in past six months? _________ If so, what?_______________________________________________________

Current Home Church: ___________________________________________________

Address: ________________________________

City/Town _________________________________ State _____ Zip Code _________

Email__________________________________________

Pastor's Name (pastor will be contacted for reference: __________________________ Are you a member? Yes ____ No ____

Please list below your church activities/offices _____________________________________________________________________

Briefly relate how and when you became a Christian __________________________ ______________________________________________________________________ ______________________________________________________________________

In your daily life, what does Jesus Christ mean to you? _________________________ ______________________________________________________________________ ______________________________________________________________________

Why are you seeking to serve in a Christian mission setting? _____________________ ______________________________________________________________________ ______________________________________________________________________

Foreign languages spoken? Languages _______________________________________ Fluent _____ Fair _____ Poor _____

                                                                                                                                                                                           Participant Release Form
Please read before signing, as this constitutes the agreement as a volunteer and the understanding of your working relationship as a volunteer with Olive Branch Baptist Church.
As a volunteer of the Olive Branch Baptist Church Mission Team, I confirm that I am going as a team member to the following mission field:_____________________________________________
to provide the following ministry__________________________________________________________________________________
I understand that this work may involve a risk of physical injury and may involve hard physical labor, 
 heavy lifting and other strenuous activity; and that some activities may take place on ladders and building 
 framing other than ground level, I certify that I am in good health and physically able to perform the type of work necessary for this mission project.
I understand that I am engaging in this project at my own risk. I understand that this is a "grass roots" 
 activity to minister to the needs of others. I assume all risk and responsibility from any damage or injury to my property or any personal injury that I may sustain while involved in this project, and related medical costs and expenses. Each individual will have the responsibility of providing his or her own health and accident insurance in the event of any illness or injury experienced during this volunteer mission.
In the event that Olive Branch Baptist Church arranges accommodations, I understand that they are not 
 responsible for my personal effects and property and that they will not provide lock-up or security for any 
 items. I will hold them harmless in the event of theft or for loss resulting from any source or cause. I further 
 understand that I am to abide by whatever rules and regulations may be in effect for the accommodations at 
 that time.
Parents are responsible for children that are minors and under the age of 18. Both parents or legal guardians 
 must sign this agreement except in the case where one parent/guardian has sole custody of the child.
By my signature, for myself, my estate and my heirs, I release, discharge, indemnify and forever hold Olive 
 Branch Baptist Church, Concord Baptist Association or Virginia Baptists together with their officers, 
 agents, servants, and employees, harmless from any and all causes of action arising from my participation 
 in this project, and travel or lodging associated therewith, including any damages which may be caused by 
 their negligence.
By my signature, as a parent of a minor under the age of 18, I give permission for my child to operate 
 power tools that are necessary to carry out the mission project. I may opt out by listing specifically which
power tools my child may not use.
By my signature, I also give permission for any photos, imagines or likeness of me to be used as a means to 
 share the mission trip with others and/or to promote interest in future mission trips. I understand this 
 includes posting photos, imagines and likeness on the church website or other internet sites. It also includes 
 presentations to church: and other groups. I may opt out by listing specifically where photos, imagines or likeness of me may not be used. _________________________________________________________________________________________________________

Signature of Participant _________________________________________________________________________________________________________Date: _____________________

Signature of Parent/Guardian if participant is a minor under 18. _______________________________________________________________Date: _____________________

Signature of Parent/Guardian if participant is a minor under 18. _______________________________________________________________Date: _____________________
 
Witness ( must be a non-relative over 18 years of age)_________________________________________________________________________ Date: _____________________