RESURRECTION LIFE CHURCH-SHORT TERM OUTREACH APPLICATION PLEASE PRINT CLEARLY AS THIS INFORMATION WILL BE USED FOR BOOKING FLIGHTS AND Today s Date: / / ACCOMMODATIONS Page 1 Outreach Location: Date of Outreach: / / Vital Information Name: Birth date: / / Male Female Address: City State Zip Email: Age Home Phone: Work Phone: Citizenship Passport # Passport exp. date Name on Passport (exactly as it appears) Marital Status: Single Engaged Married Divorced Widowed Separated Spouse: Years Married: Birth date: Children: Name: Age: Name: Age: Name: Age: Which family members will also participate in this outreach? Emergency Contact Information Primary Contact Name: Relationship to self: Home Phone: Work Phone: Email: Secondary Contact Name: Relationship to self: Home Phone: Work Phone: Email: 1
Church History & What You Believe How long have you regularly attended Resurrection Life Church, Rockford? Do you regularly attend a church other than Resurrection Life Church, Rockford? If yes, where do you attend? Are you a born again Christian? Yes No How long? Please check the statements that apply to you. I believe. the virgin birth and deity of Jesus Christ. that Jesus is God s Son and only sacrifice for sin. that Jesus rose bodily from the dead. that a person must be born again to receive eternal life. in the infallibility of the Holy Bible. in eternal damnation for the lost. List three STRENGTHS List three WEAKNESSES 1. 1. 2. 2. 3. 3. Where Is Your Passion For Ministry? Adults Bible teaching Helps Strengthening Marriages Men Praise & Worship Special Needs Building/repairing houses Women Children s Disaster relief work Other Ministry Youth Prayer Serving the poor Other Childre Drama Recreation/Activities n Parents Evangelism Singles Briefly explain why you would like to participate in this outreach : 2
References (Please provide the name of two personal references (exclude family members), and one pastoral or ministry supervisor reference.) Name Relationship Phone State Pastor or ministry supervisor By signing below, I certify that the information contained in this application is complete, accurate, and not misleading in anyway. I authorize Resurrection Life Church, Rockford and its agents to contact references provided, as well as any sources not provided in order to obtain information regarding my character and fitness for this outreach. Should my application be accepted, I agree to submit to the policies and procedures of Resurrection Life Church, Rockford Short Term Outreach Ministries, and to refrain from unscriptural conduct in the performance of my services on behalf of Resurrection Life Church, Rockford. Signature of Applicant: Date: / / For office use only: Application Approved Application Denied Further Review Needed 1 st Approved by : Date: Application Approved Application Denied Further Review Needed 2 nd Approved by: Date: Background check approved Beliefs ok Medical ok Confirmation of approval/denial D ate: Initials: 3
RELEASE OF LIABILITY I, hereby release all leaders and organizations involved with Resurrection Life Church, Rockford outreach to hold harmless from any and all legal liability. I hereby waive my rights to any legal liability, on the part of Resurrection Life Church, Rockford or any other individuals or organizations involved, which liability may result from sickness, injury, or death that may occur on or related to this outreach. I fully realize that there are hazards, and I am fully assuming these risks, included but not limited to hazardous traffic, poorly constructed roads, dangers resulting from military or political problems, sickness and disease. I specifically release Resurrection Life Church, Rockford and all concerned, from any claim of negligence in their duties as leaders, or otherwise in this outreach. In the event that I would make a claim, I shall pay all legal fees and costs incurred by Resurrection Life Church, Rockford and other individuals and organizations involved. I further hereby authorize the leadership of Resurrection Life Church, Rockford to make essential decisions on my behalf with respect to medical treatment, emergency surgery or hospitalization should such be necessary. However, Resurrection Life Church, Rockford shall in no way be responsible or liable for any medical bills incurred related to this outreach. Should it be necessary for me to return home due to disciplinary action, I assume the extra transportation costs. I agree to whole heartedly abide by all rules, regulations and guidelines set forth in the Resurrection Life Church, Rockford training materials, and to abide by all decisions made by all leaders and those in authority. Participant Signature Date Participant's Printed Name 4
Page 5 MEDICAL INFORMATION Please list any prescription medications you are taking and the reason(s) for taking: Please list any food or medicine allergies you are may have and what those reactions are: Are you under a doctor s care for any reason? Please explain: Do you require a special diet? Yes No (If Yes, please explain) Can you swim? Yes No Do you have any physical condition or illness that would prevent you from participating in rigorous activity? Yes No (If Yes, please explain) If you answered YES to the above question, a written release must be submitted by your local physician authorizing you to participate in Missions activities. I certify that I have personal health insurance with the following company. A lack of personal health insurance will not limit your participation in this outreach. Company Name Policy Number Family Physician Physician s Work Phone 5
MINOR DISCLAIMER FORM TO BE FILLED OUT BY PARENTS OF MINOR PARTICIPANTS Disclaimer : Proposed Activity : Resurrection Life Church, Rockford Missions trip First : We are the adult natural parents or Parents / Legal Guardians Names Legal Guardians of, (hereinafter referred to as "Participant"), a minor of Child s Name years and months of age. Second: Participation Disclosures and Waivers The participant and the parents understand and agree that there are a number of various programs undertaken in affiliation with Resurrection LIfe Church, Rockford involving activities and individuals that are often not under direct control or supervision of, Resurrection LIfe Church, Rockford and that there is an overriding policy that each participant involved in these programs does so at their own risk of personal injury or damage to property; and, Participant desires to take part in the activity mentioned herein above, and fully understands and agrees that such activity might involve sporting activities, travel or contacts with other individuals or groups, and that Resurrection LIfe Church, Rockford has limited or no control over other individuals involved in such activity; and that there is always the risk of physical injury, illness, and other loss, and possible costs or expenses for medical or dental diagnostic and curative treatments, and general and special damages for incidental loss or expense; and, in these premises, Participant does for himself/herself, and for and on behalf of said Participant and his or her family, representatives and heirs, assume the risk of responsibility or sort of loss or injury of or to person or property of any description in the regard, and as an inducement to Resurrection LIfe Church, Rockford and its agents to allow the undersigned and Participant to participate in such activity, does hereby agree to hold harmless Resurrection LIfe Church, Rockford and its agents from all these things in event any such claim should arise. Resurrection LIfe Church, Rockford does not act as an insurer, guardian, guarantor or warrantor of health or safety of anyone involved in such activity. Third: Medical Authorization Whereas, my child, wishes to be a member of a Resurrection LIfe Church, Rockford team which will be traveling, and whereas, certain circumstances and situations may occur resulting in my child s need for medical/dental care and treatment, and further resulting in my inability to personally give consent for such care and treatment; Therefore, 1. In consideration of permission for my child to participate in said mission, I authorize Resurrection LIfe Church, Rockford or any agent of Resurrection LIfe Church, Rockford to act in my child s behalf should I be unable to do so and to consent to reasonable medical/dental care and treatment, including but not limited to diagnostic tests, x ray examinations, anesthesia, surgery and other procedures that may be deemed necessary for my child s medical well being for the duration of the mission trip. 2. This consent is given in advance of any specific diagnosis, treatment, surgery or hospital care required, but is given to provide authorization and specific consent for medical/dental treatment and care in my child s behalf. 3. Any consent by shall have the same force Resurrection LIfe Church, Rockford and effect as if I had personally given the consent. 4. I hereby release and hold harmless Resurrection LIfe Church, Rockford, its officers, employees and representatives/volunteers from all liability for all hazards and risks associated with such a trip including, but not limited to, death or injury by accident, disease, terrorist acts, weather conditions, inadequate 6
medical services and supplies, criminal activity and random acts of violence, as well as all property damage or loss arising out of my child s participation in this trip. Fourth: Discipline The participant and their parents hereby submits to and agrees to abide by all rules and regulations, supervision and discipline set and applied by Resurrection Life Church, Rockford or its agents, and it is agreed that for violation of such rules and regulations, supervision or discipline, the participation in the said activity may then be immediately terminated, without liability on Resurrection LIfe Church, Rockford or its agents. Fifth: Parental Travel Consent Form I hereby have given my child permission to travel to the designated country during with provided supervision by Resurrection LIfe Church, Rockford through its adults serving as its agents. If my last name differs from my child s last name, I will provide a copy of my child s Birth Certificate or legal guardianship documents following the notarized document on page seven. Sixth: Volunteer Status My child is a volunteer and I acknowledge that they will not receive any payment from Resurrection life Church, Rockford, for their participation on the mission trip. Seventh: Video & Photographs As on any trip there are often videos and/or photographs taken during the mission trips. From time to time, Resurrection LIfe Church, Rockford would like to use these videos or photos on Facebook, in newsletters, on the Resurrection Life Church, Rockford website or for marketing purposes to allow others to see the impact these mission trips have. We would never provide any specific information regarding your child. These videos or pictures will never be sold and would only be used exclusively for Resurrection Life Church, Rockford purposes. Therefore I give Resurrection LIfe Church, Rockford the right to use my child s picture, voice, and/or testimony in any type of promotional or advertising materials. Eighth: I waive any and all claims for damages which I, or my heirs or successors, may have against the General Council of the Resurrection Life Church, Rockford arising from my child s death, injury, illness or any property damage or loss occurring during the term of my/my child s assignment or as a result of my/my child s assignment. Ninth: I understand and accept the following policy of the General Council of Resurrection Life Church, Rockford regarding ransom payments: The General Council of the Resurrection Life Church, Rockford has determined that it will not pay ransom nor yield to the demands of anyone who takes hostage one of our staff or volunteers. The General Council of the Resurrection Life Church, Rockford pledges themselves 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. Participant s Signature Date Father/Legal Guardian s Signature Date Mother s Signature Date 7
TRAVEL CONSENT NOTARIZATION FORM We and the (Father s first and last name) (Mother s first and last name) parents of give our child permission to travel (Child s first and last name) to with Resurrection Life Church, Rockford (Country) for the month of. NOTE: (Month of Trip) Parents, if your last name differs from your child s last name, you are required to attach a certified copy of their Birth Certificate along with this document. If both parents have custody, both signatures are required! If one parent has sole custody, please provide proof. PLEASE SIGN BELOW IN THE PRESENCE OF A NOTARY: After being duly sworn, declares that he/she has read and signed the foregoing Medical Authorization, Disclaimer and Travel Consent Agreement at his/her own free act and deed. Mother/guardian signature: Print Name: Father/guardian Signature: Print Name: NOTARY AREA: Subscribed and sworn to before me this day of, 20. Notary Public Date (Notary Stamp) 8
BACKGROUND CHECK AUTHORIZATION FORM AUTHORIZATION I hereby authorize, without reservation, the obtaining of consumer reports or investigative consumer reports by Resurrection Life Church, Rockford at any time after receipt of this authorization and throughout my employment or volunteer service, if applicable. I further authorize and request, without reservation, any present or former employer, school, police department, state or federal agency, financial institution, division of motor vehicles, consumer reporting agencies, or other persons or agencies having knowledge about me to furnish SecureSearch or Resurrection Life Church, Rockford with any and all background information in their possession regarding me, so that my employment and/or volunteer qualifications may be evaluated and/or reassessed. I also agree that a fax or photocopy of this authorization with my signature should have the same authority as the original. By signing below, I certify: (1) that I have read and fully understand this disclosure and authorization; (2) that all of the information I am providing is true, complete, correct and accurate; and (3) that I have received the attached Summary of Your Rights under the Fair Credit Reporting Act (15 U.S.C. 1681 et seq.). The following is information required in order for Resurrection Life Church, Rockford to obtain a complete consumer report: FULL LEGAL NAME (First, Full Middle Name, Last Name) SOCIAL SECURITY NUMBER DATE OF BIRTH* STREET ADDRESS CITY, STATE, ZIP CODE DRIVER S LICENSE NUMBER ISSUING STATE OTHER OR FORMER NAMES (AKA, Maiden Names, Married Names, Surnames, Etc.) CONSUMER S SIGNATURE DATE * This information will be used for background screening purposes only. Please list all Counties and States you have lived in since the age of 18. County State Name Used in County Date From Date To 9
DISCLOSURE The following are my responses to questions about my criminal record history (if any) with descriptions to any question with a YES answer: Name : 1. Have you ever been convicted or plead guilty before a court of any federal, state, or municipal criminal offense? (Excluding minor traffic violations) Yes No If Yes, please explain: 2. Have you ever received deferred adjudication or similar disposition for any federal, state or municipal criminal offense? Yes No If Yes, please explain: 3. Have you ever received probation or community supervision for any federal, state or municipal criminal offense? Yes No If Yes, please explain: 4. Have you ever been convicted of any criminal offense in a country outside the jurisdiction of the United States? Yes No If Yes, please explain: 5. As of the date of this authorization, do you have any pending criminal charges against you? Yes No If Yes, please explain: 6. Have you ever served in the US Military? Yes No 7. If you answered YES to the above question, did you receive a DD214? Yes No If Yes, can you present the document?: Yes No 8. If you answered YES to the above question 6, did you receive an honorable discharge? Yes No If No, please explain: _ Consumer signature Date OFFICE USE ONLY Dept. Requesting Form: Missions Dept. Signature : 10
Resurrection Life Church, Rockford Short-Term Outreach / Training Support Request Name of Applicant: Phone Number: Date: Email: What is the name of the organization you will be with? Where is the outreach or training program? When are you leaving / returning? What is the total cost? What amount do you currently have? What have you done to work, save, and sell items to obtain funds? In addition, what have you done to ask people to partner with you in giving? What is the total amount you believe you will be able to pay and/or raise? What do you hope to gain from this experience? 11
Short Term Outreach Payments/Contributions Payments/contributions from yourself for the outreach you are going on: Option 1:Contributions Personal funds that you put towards your short term outreach will be treated as contributions. *If for any reason you decide not to go or are unable to go on the trip then these contributions can not be returned to you. At year end, you will receive a statement for tax purposes. When you are dropping off or mailing a check, please enclose a note with the name of who you would like to support (in this case yourself) and the name of this outreach. (For example: I would prefer the donation to support Mary on the Honduras Outreach). Make all checks payable to Resurrections Life Church, Rockford. Contributions from others: Tax deductible contributions for short term missionary trips must be made to or for the use of a particular trip. When asking others to make a tax deductible donation towards the trip to cover your part please use the following wording (this is in the sample fundraising letter). For a tax deductible receipt, please make your check payable to Resurrection Life Church with a note attached that states that you prefer the money be applied towards my outreach expenses. Please do not write my name on the memo line or anywhere on the check. Any donations received above and beyond the cost of my portion of the outreach will be used for our overall ministry in (fill in the name of country/place) or for a future missions outreach that I participate in. * We cannot stress enough that if the above instructions are not followed it is likely that the donation will not be tax deductible. If you have any questions, please call the missions assistant at (913) 829 7511. Short Term Outreach Airfare Policy All trips will use the Resurrection Life Church, Rockford chosen travel agent and source for insurance. (We have good reasons for this. Please ask your outreach leader if you want more information.) Frequent flyer miles can not be used to help purchase team members flights. However, they can be accumulated. Participants need to register their number at the airport (if there is time) or may keep their boarding passes and do it once they get home. 12