Short-Term Mission Application


  Heartland Missions
  Heartland Community Church
  3253 Brush College Road
  Decatur, IL 62521
  
  (217) 877-9529 – office
  

 Mission Trip Preference 1:

Mission Trip Preference 2:
General Information
Full name as it appears on your passport:
First Name: Middle Name: Last Name: Preferred Name:
Country of Citizenship: Social Security Number:
Date of Birth (MM/DD/YYYY): Passport Number or N/A:
Marital Status: Spouse (if married):
Home Address: Home Phone:
City: Email:
State: Fax Number:
Zip:    
Place of Employment: Work Phone:
Job Title: May we call you at work?
Emergency Information
Do you have any medical restrictions or disabilities that we need to make provision for?
If yes, please explain:
Known allergies to medications, pollen, food, etc.
Reactions to allergies
Has your reaction ever required emergency care?
If yes, please explain:
Do you have any recurrent health problems (chest pains, kidney problems, etc.)?
If yes, please explain:
Are you presently taking any medications?
If yes, please explain:
In the event of an emergency notify:
Name: Relationship:
Address: Day Phone:
City: Evening Phone:
State:    
Zip:    
Church Membership Information
Are you a member of HCC? Year Joined:
Please state the ministry(ies) that you are involved in (e.g., Youth, Single Adults, etc.):
Complete information below if you are not a member of HCC
Describe your relationship with HCC (check all that apply):
Regularly Attend      
Former Member Dates of Membership:
Referred to HCC by:
Additional Information:
Church where you are a member:
Address:
Phone Number: Pastor's Name :
Please state the ministry(ies) that you are involved in outside of HCC:
Skills
What languages do you know other than English?
Check any of the skills below that apply to you. Give further information / explanation if necessary. Please
list other skills that may be utilized on a short-term mission trip (drama, Juggling, etc.).
Personal Ministry
Training
Medical
Business
Computer
Bible Study Leader Bible Doctor Accounting Programming
Evangelism ESL Nurse Management Networking
Singing Marriage Dentist Marketing Web Design
Musical Instrument Apologetics Nutrition Training
Pharmacist
References
Please list below three (3) people that we may contact who have known you at least two years and who
know your ministry abilities as well as your strengths and weaknesses. These should be from outside your
family, and at least one person should be in a ministry position at Heartland.
Name: Address:
Known Since: City:
Relationship: State:
Day Phone: Zip:
Evening Phone:    
Name: Address:
Known Since: City:
Relationship: State:
Day Phone: Zip:
Evening Phone:    
Name: Address:
Known Since: City:
Relationship: State:
Day Phone: Zip:
Evening Phone:    
Please write one or two paragraphs on the following
Write a description of your relationship to Christ including how you became a Christian.
Why do you want to be on a short-term mission team?
What are the realistic roadblocks that might keep you from going on a mission trip?
What short-term teams have you been on before (dates, destination, organization, purpose)
What other overseas travel experience do you have?
What gifts or abilities do you feel that you bring to a team?