Application

Please mail all forms and a copy of your

passport to:

XA
Attn: Missions
PO Box 2777
Norman, OK 73070

Or email:
xaoklahoma@aol.com
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What trip are you applying for?

___________________________________________________________________

General Information
Last Name ________________________ First Name ________________________

Middle Name ____________________ Name You Prefer _____________________

______Male ______Female

Address _____________________________________________________________

Apartment Number__________

City ______________________________ State __________ Zip_______________

Cell Phone ____________________ Email Address _________________________

Passport number ___________________________________ State _____________

Team Leader’s Name __________________________________________________

College or University ___________________________________________________

Major ________________________________________________________________

Campus Pastor’s name _________________________________________________

Home Church_________________________________________________________

Pastor’s Name ________________________________________________________

Pastor’s Phone _____________________ Email______________________________

Character Reference: Name ______________________________________________

Phone __________________________ Email ________________________________

How would you rate your physical condition?

_____Excellent _____Good ______Fair _____Poor

Height__________ Weight______________ Date of Birth_________________

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Do you have any physical conditions or disabilities that require special medical attention
that we should know about? If yes, please explain. Use a separate sheet if necessary.

______________________________________________________________________

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Are you presently taking any type of medication? If so, please explain.

______________________________________________________________________

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Are you currently under a doctor’s care for a medical and/or psychological condition? If
so, please describe.

______________________________________________________________________

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If you answered yes to question three, would this condition potentially hinder your
participation in a missions project? Please explain.

______________________________________________________________________

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Personal Questionnaire:
(Feel free to use an additional sheet of paper if necessary.)

Describe your salvation experience.

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Have you ever led someone to the Lord? Describe what happened.

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Have you taken previous missions trips? Where did you go? What group did you go
with? What did you do?

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Why do you want to go on this trip?

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What are your strengths and how will you and your strengths benefit this team?

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What are your weaknesses? How will you overcome them so as not to hinder this
team?

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Describe your relationship with God.

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Describe your devotional life. On a scale of 1-10, with 10 being the highest, what would
you rate it?

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Who are your personal role models/heroes? Why?

______________________________________________________________________

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What areas of ministry are you currently involved in? What areas have you been
involved with in the past?

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What fears or apprehensions do you have about an international missions trip?
______________________________________________________________________

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Missions Team Member Commitment

As a disciple of Jesus Christ and a member of a Chi Alpha Missions team, I commit
myself while on this missions Expedition to follow the example of Jesus in responding to
all people.
I will put the needs of others before my own.
I will walk with the attitude of Jesus under all circumstances and conditions.
I will be flexible and encouraging when our plans abruptly change.
With the exception of medical reasons, I will eat everything set before me and will
thank the Lord for it.
I will not speak negatively towards people on our team, our missionaries, or the
people that I have come to serve.
I commit to respect and submit to the local missionary, my team leader, and all those
who are in authority over me.
I commit that no complaining word will come from my mouth during our mission. I will
speak words of life and encouragement to our team and all those who I meet. I will live
in accordance to the Word of God during this missions expedition.

Chi Alpha Student ______________________________ Date____________________

Accountability Witness __________________________ Date_____________________

Assumption of Risks
I, _____________________ (name of volunteer), in consideration of my acceptance as
a short-term volunteer with the Missions Abroad Placement Service (MAPS) of the
Assemblies of God World Missions of the General Council of the Assemblies of God,
USA, represent and agree that:
I am a volunteer worker and acknowledge that I am not an employee of MAPS, the
Assemblies of God World Missions, or the General Council of the Assemblies of God,
United States of America.

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I am aware of the hazards and risks to my person and property associated with serving
in a missions capacity, such hazards and risks including, but not being limited to, death
or injury by accident, disease, war, terrorist acts, weather conditions, inadequate
medical services and supplies, criminal activity, and random acts of violence. I accept
my assignment with full awareness of these risks and, subject to the insurance
coverage described below, I voluntarily assume all risks of death, injury, illness, and
damage to myself or any member of my family associated with such risks and any
damage to my personal property. I further recognize that such risks have always been
associated with missionary service.
(2Corinthians 11: 23-28)
I attest and certify that I have no medical conditions that would prevent me from
performing my duties.
Subject to insurance coverage described below, I waive and release any and all claims
for damages which I, or my heirs or successors, may have against MAPS, the
Assemblies of God World Missions, the General Council of the Assemblies of God, any
District Council of the Assemblies of God, the local church sponsoring the MAPS trip, or
any agent or employee of any of such organizations, arising from my death, injury, or
illness, or any property damage or loss occurring during the term of my assignment or
as a result of my assignment.
In the event that I have minor children who will accompany me on my assignment, I,
acting both on my own behalf and in their behalf as their parent and legal guardian, and
subject to the insurance coverage described below, do hereby assume all risks of
death, illness, or injury they may suffer as a result of said assignment, from those
causes described above.
I understand and accept the following policy of the Assemblies of God World Missions
regarding ransom payments: The World Missions Board has determined that it will not
pay ransom nor yield to the demands of anyone who takes hostage one of our
missionary family or staff hostage. The Assemblies of God World Missions pledges itself
to every effort in prayer and all other appropriate means to obtain the release of one
taken hostage should it ever occur. This policy was made after sufficient study of the
policies of other evangelical missionary societies and after considering the advice of the
United States State Department.
I expressively waive any defense to the enforcement of any provision of this
commitment arising from a claim of lack of consideration and warrant that this
commitment constitutes a legal, valid, and binding obligation upon me enforceable
against me in accordance with its terms.
I expressly agree that this assumption of risk and indemnity agreement is intended to be
as broad and inclusive as permitted by law. I further state that I HAVE CAREFULLY
READ THE FOREGOING ASSUMPTION OF RISK AND UNDERSTAND ITS
CONTENTS, AND I VOLUNTARILY SIGN THIS RELEASE AS MY OWN FREE ACT.

Signed _____________________________________________ Date_____________

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I, ___________________ , hereby release Chi Alpha, its agents, assignees,
employees, and volunteers of any liability for injury, sickness, or damage which may be
sustained while on the course of this trip.

MEDICAL RELEASE
I give my consent for the director or properly appointed staff member of Chi Alpha to
secure the administration of medical treatment and/or medication for myself, and I do
further agree to the performance of such treatment, anesthetics, and operations as in
the opinion of the attending physician if deemed necessary.

LIST ANY MEDICATIONS OR TREATMENT THAT SHOULD NOT BE GIVEN TO YOU

BECAUSE OF HEALTH RISKS:

______________________________________________________________________

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Guarantee Trust Life Ins
(Your)Last ____________________ First __________________ Middle Initial ______of
Travel
Month __________ Day _________ Year __________
Beneficiary’s Name
(Beneficiary)
Last _________________________ First __________________ Middle Initial _____

Beneficiary’s Relationship to Insured __________________________________

Additional Insurance (optional):

Policy holder __________________________________________________________

Policy Number ________________________________________________________

Participant Signature ____________________________________ Date __________

Print Name ____________________________________________________________

Signature______________________________________________________________

(Witnesses should not be relatives and must be 18 years of age or older.)

Witness Print Name ___________________________________________ Date: _____

Witness signature _______________________________________________________

Witness 2 Print Name _________________________________________ Date: _____

Witness 2 Signature _____________________________________________________

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 AGWM
Background ● Check ● Release
As a short-term volunteer with the World Missions of the General Council of the
Assemblies of God, I authorize my permission for AGWM to run a background
check by signing and providing the pertinent information below.

Signature ___________________________________ Date _______________

Print Name Legibly ______________________________________________________

Current Physical Address (No P.O. Boxes please)

Address:
______________________________________________________________________

City ______________________________ State ______________ Zip _____________

Previous Physical Address

Address:
______________________________________________________________________

City _______________________________ State______________ Zip_____________

Date of Birth _______/_______/________ Social Security Number ____________________

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