Mission Trip Application Name(Required) First Last An application must be filled out by each family member going on the trip.Please indicate Location and Dates of trip you are applying for. Are you a BMDF member? Yes No Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Personal Email(Required)Please do not use .edu address. Enter Email Confirm Email Cell Phone(Required)EducationWhat is your current level of education? High School Student High School Graduate Undergraduate University Student Undergraduate University Graduate Graduate University Student Completed Graduate studies Other If you are a family member accompanying a parent and under the age of 18, please list your age.Undergraduate Institution Undergraduate Institution Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Undergraduate Degree Program Undergraduate Graduation Year Professional/Graduate InstitutionMedical School, PT School, Pharmacy School, etc. Professional/Graduate Degree Program Professional/Graduate Institution Graduation Year LicenseIf you hold a current healthcare license, please share the following information.Type of License State of Issue License Number Expiration Date MM slash DD slash YYYY Emergency ContactEmergency Contact Name(Required) First Last Emergency Contact Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact Phone(Required)Mission ProjectMission Project Date(Required) Why do you think God is leading you to participate in this project?(Required)What do you expect to gain from this mission trip?(Required)Church(Required) Pastor Name(Required) First Last Church Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code ReferencesPlease include: Reference 1) Pastor or Church Leader, Reference 2) Co-worker, work supervisor, professor, or leader from your current institution, and Reference 3) a friend, church members, peer, or classmate.Reference 1 Name(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Suffix Reference 1 Email(Required) Reference 1 Phone(Required)Reference 1 Relationship to You(Required) Reference 2 Name(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Suffix Reference 2 Email(Required) Reference 2 Phone(Required)Reference 2 Relationship to You(Required) Reference 3 Name(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Suffix Reference 3 Email(Required) Reference 3 Phone(Required)Reference 3 Relationship to You(Required) OtherHow did you find out about this volunteer opportunity?(Required)What are you doing to prepare yourself spiritually for this project?(Required)Do we have permission to do a background check on you?(Required) Yes No Signature(Required)I acknowledge and agree with the BMDF Statement of Faith for this trip. The statement of Faith has a link attached which takes them to the Who we are page of the website.
