Application | United Christians International

UCI Haiti Trip Application Form

Website *

Name (First/Middle/Last) *

Nickname? *

Gender *

Male

Female

Age *

Personal Weight (pounds) *

Must know for MFI flight

Birth Date (Month/Day/Year) *

Birthplace (Country) *

Citizen Of (Country) *

Occupation *

Passport Number *

Available forms of ID (Note if you have) Driver's license of permit, Birth Certificate

Expiration *

Address *

Street, City, State/Province, Zip Postal Code, Country

Telephone (Home) *

Area Code + Number

Work/Cell (Optional) *

Area Code + Number

Email *

Additional Email *

List a character reference whom we may contact, a pastor or leader

Name *

Relationship to you *

Email *

Address *

Street, City, State/Province, Zip Postal Code, Country

Telephone (Home) *

Area Code + Number

Home Church

Church Name *

Pastor *

Address *

Street, City, State/Province, Zip Postal Code, Country

Telephone *

Area Code + Number

Email *

Additional Email *

In case of emergency, please notify

Name *

Relationship to you *

Telephone (Home) *

Area Code + Number

Work/Cell *

Area Code + Number

If applicable, who will be your parent-approved supervisor?

Name *

Relationship to you *

Telephone (Home) *

Area Code + Number

Work/Cell *

Area Code + Number

Describe your relationship with Jesus in your own words

List any talents/skills that the Lord may use on this mission

(Art/crafts/music/drama/electric/plumbing/carpenter/construction /mechanic/pastor/teacher/special categories [example: love children, enjoy gardening], etc.).

Please describe your health, including any physical or dietary limitations

(Include any that apply: diabetes, asthma, physical disability, heart trouble, epilepsy, high or low blood pressure, fainting, pregnancy, allergies of any kind [food, medicine, environmental, insect bites/stings], etc.)

Are you currently under a doctor’s care or medication? (If yes, please explain)

Primary Care Physician

Name *

Clinic *

Telephone *

Area Code + Number

Work/Cell (Optional) *

Area Code + Number

Date of last Tetanus Shot *

Blood Type (If Known) *

(To find out your blood type: donate blood, check with your doctor, or buy a home kit [www.testsymptomsathome.com or 888.595.3136].)

I am able to walk several miles or “rough it” on this mission.

Yes

I agree to abide by the UCI policy to abstain from alcohol, tobacco, and illegal drugs during this entire mission.

Yes

Tell us anything else we should know about you *

Insurance Provider

Provider *

Address *

Street, City, State/Province, Zip Postal Code, Country

Telephone (Home) *

Area Code + Number

Policy Number *

Group Number *