Name (as on passport) *

First Name

Last Name

Sex *

Male

Female

Martial Status *

Single

Married

Engaged

Windowed

Divorced

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Phone

(###)

###

####

Cell Phone

(###)

###

####

T-Shirt Size *

Small

Medium

Large

X-Large

XX-Large

Do you have a passport? *

Yes (If yes, please fill out the information below)

No

Not yet

Have you completed immunization for travel?

Yes

No

Not yet

Name(as on passport)

First Name

Last Name

Issue Date

MM

DD

YYYY

Expiration Date

MM

DD

YYYY

Facebook

Yes

No

Twitter

Yes

No

Instagram

Yes

No

Previous Mission Trip Experience *

Yes

No

Foreign Missions

Yes

No

In State

Yes

No

Date of Most Recent Trip

MM

DD

YYYY

Type of Trip

Evangelistic Outreach

Children/Youth

Sports

Medical

Construction

Humanitarian

Disaster Relief

Work Telephone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Type of School *

College

Trade/Technical School

High School

Middle School

Home School

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Academic Year

Freshman

Sophomore

Junior

Senior

Grad Student

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary

(###)

###

####

Mobile

(###)

###

####

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary

(###)

###

####

Mobile

(###)

###

####

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary

(###)

###

####

Mobile

(###)

###

####

Church Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Church Phone

(###)

###

####

Church Website

Yes

No

Healthcare Contact Number *

(###)

###

####

Healthcare Provider Contacted About This Trip

Yes

No

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Telephone *

(###)

###

####

Immunizations Current *

Yes

No

Special Dietary Needs *

Yes

No

Special Medical Needs *

Yes

No

Are You Currently Taking Any Prescription Information *

Yes

No

Any Physical Limitations? *

Yes

No

I hereby agree to the performance of any medical treatment, including anesthetics deemed necessary by the attending physician in the event that I am unable to make these decisions for myself. I hereby release Cornell Jordan Ministries, Kent, Ohio, and all persons affiliated with this ministry from any liability arising from any injury, damage, or loss which may be sustained by me during my course of involvement with a short-term outreach trip. I also release Cornell Jordan Ministries, Kent, Ohio, from any liability for health impairment or bodily injury as a result of any pre-existing health condition. I will be responsible for monitoring and managing all aspects of any pre-existing condition. *

I Accept

Nonrefundable Application Fee *

Are you able to submit the $100 non-refundable application fee immediately..

Yes. I can do it.

No. Not right now.

Support Letter

Would you like us to send you and example of a support letter that can be sent to family and friends?

Yes please.

No thank you.

Financial Support *

I understand that upon the purchase of flight tickets, any support sent in other than my own will not be reimbursed to me or the donor.

Yes. i understand and agree.