Mission Nicaragua – Returner Application This application is only for applicants that have previously been a team member with us on Mission Nicaragua. Step 1 of 4 25% Today's Date* Date Format: MM slash DD slash YYYY Personal InformationName* Please print your FULL legal name as it appears on your passport for airline ticket purposes.Date of Birth* Date Format: MM slash DD slash YYYY Marital StatusSingleEngagedMarriedWidowedSeparatedDivorcedIf Married, Spouse's Name:Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Home Phone*Cell PhoneWork PhoneIs it ok to call your work? Yes No OccupationWork HoursDo you attend Wildwood Church?*Yes, I am a memberYes, as a visitorNo, I attend a different churchName of church you attend Legal WaiverWe will need a signed waiver to keep on file. If you are under 18 a parent's signature will also be required.By checking the "I agree" box I agree to the following: I am aware that all positions are voluntary, without financial remuneration. I agree to abide by all present and subsequent issued rules of Wildwood Church. I clearly understand that raising all expenses, including travel to and from the designated training location, will be my responsibility. I further agree that Wildwood Church has the right to discontinue my ministry at any time at its sole discretion. I recognize that participation on a trip of this nature may be hazardous or dangerous. Therefore, I am, for myself, my heirs, executer and/or administrator, releasing and forever discharging Wildwood Church and all its officers, agents, servants, and employees, acting officially or otherwise, from any and all reason of injury, damage (including property damage to any of my belongings), loss or death which may occur from any cause including, but not limited to, any accident and/or occurrence while participating individually or with others while with this mission agency and/or on this mission trip. Furthermore, I realize all contributions to Wildwood Church are tax-deductible. Contributions are non-refundable in the event that the applicant chooses not to participate in the program. The financial disbursement of these funds is at the discretion of the Foreign Mission’s Committee of Wildwood Church. I have read the above and understand my commitment to participate and my financial commitment. The information I have given Wildwood Church is accurate and true to the best of my knowledge. I also give Wildwood Church the right to use my picture, voice and/or testimony in any form of promotional advertising materials.* I agree General HealthIf under 18 we will also need a notarized medical release form with a copy of insurance card on file.Medical History* None Asthma Seizures Hepatitis Diabetes Cancer Nervous Breakdown Rheumatic Fever Stomach Ulcers Eating Disorder Psychiatric History Leukemia Tuberculosis Fainting Spells Aids/HIV Depression Excessive Fatigue High Blood Pressure STD Incapacitating Headaches Other Please indicate if and when you have had any of the above.Please explain:Are you currently taking any medications?* Yes No List Medications:Please list all medications (name and dosage) you are currently taking.Do You have any allergies?* Yes No Including allergies to medications, foods, etc. List Allergies:Please also describe reactions.Do you have any special dietary needs?* Yes No List Dietary Needs:Please check any of the following conditions if there is any reason why you cannot tolerate:Rigorous Outdoor ActivityLow TemperaturesHigh HumidityHigh TemperaturesHigh AltitudesOtherPlease explain tolerance:Your Temperament* Impulsive Introspective High-Strung Self-Conscious Moody Shy Calm Aggressive Easy Going Dominant Please indicate which of the above characteristics seem to apply to your temperament.Emergency Contact InformationPlease DO NOT list a team member as your emergency contactEmergency Contact Name* Relationship to contactSpouseParentChildOther RelativeFriendContact's Home PhoneContact's cell phone Personal TestimonyPlease describe your spiritual journey over the last few months- the highs and the lows:*Please list some of the things you feel God taught you in Nicaragua previously? Do you feel it was life-changing or short term change? If it didn't "stick" why do you think that is so?*Ministry InvolvementSince you have returned from Nicaragua, how well do you think you have lived a life on mission here in Tallahassee? What have you participated in locally or beyond (describe and share how often) ?* MissionAs a returner, do you have expectations for this trip? Are they different than last year?*Since space is limited, would you be willing to give up your spot so someone new could come? If you are placed on the team, you will be coming with "experience", how do you think that will benefit the team?*What strengths/abilities/talents do you have that would contribute to this mission?*Are you fluent/conversational in any languages other than English? Yes No Languages you are fluent/conversational:
