Please take the time to fill in each blank.  Incomplete applications will not be considered for team placement. 

TEAM INFORMATION:

   Camp Team #1 - School Orphanage #1, Mariupol, Ukraine 
Dates: June 22 - July 7, 2007
Cost: $2,400 (DFW or Chicago departure) $2,500 (LAX departure)

   Camp Team #2 - Solnichne Toddler Orphanage, Mariupol, Ukraine
Dates: July 6 - July 21, 2007
Cost: $2,400 (DFW or Chicago departure)

    Team #3 - Computer Camp at Jeremiah's Hope TLC
Dates: July
Cost: $2,000 (DFW or Chicago departure)

PERSONAL INFORMATION: (Full LEGAL name as it appears on passport)

First

Middle

Last

Passport #

Expiration Date of Passport

Date of Birth Age

Address

Phone # (with area code) 

E-mail

Cell Phone #   Marital Status Single Married Divorced

CHURCH INFORMATION:

Church Home

Mission Committee Chair or Elder of Missions

Phone # for above mentioned contact

EXPERIENCE:

Do you have domestic or foreign mission experience?  Yes No

Describe your missions experience:

Have you ever lived in another country?  No Yes  

Which countries have you traveled too?

PHYSICAL INFORMATION:

Do you have any medical conditions for which you are receiving treatment? No Yes

Do you have any physical limitations? No Yes

Are you presently taking any medications? No Yes

If so, what medications are you taking and for what purpose:

Are you presently under a doctor's care? No Yes

Are you being treated or have been treated for phsychological or emotional disorders? No Yes

If yes, may we discuss this with you if we have questions? No Yes

EMERGENCY CONTACT INFORMATION:

Jeremiah's Hope will need an emergency contact person on file in care of an emergency.  We will also take the responsibility to contact them prior to your departure to confirm that they are your contact person.

Name Relationship Spouse Parent Friend Other

Address

Phone # (with area code)

Cell Phone # (with area code)

Work Phone # (with area code)

E-Mail

REFERENCES:

Please provide two names whom Jeremiah's Hope might contact as references.  Consider an elder or ministry leader from your church, an employer or teacher, a former team member of a previous mission trip elsewhere.  Please do not submit family members, boyfriend/girlfriend or best friends as references.

Reference #1 Name

Relation to you

Phone # (with area code)

E-Mail

Reference # 2 Name

Relation to you

Phone # (with area code)

E-Mail

PERSONAL COMMITMENT:

Are you willing to make changes in personal habits and/or dress to avoid being offensive in another culture or to your teammates? No Yes

Are you will to raise and provide your portion of the ministry funds by the announced deadlines? No Yes

AUTOBIOGRAPHICAL INFORMATION:

What are your interests, hobbies, sports, etc?

What is your occupation and basic work world like?

Please describe your personal relationship with the Lord at this time?

What activities are you involved with in your home/local congregation?

What are the 3 greatest blessings God has given you?

COMMITMENT:

If accepted to serve on a mission team with Jeremiah's Hope, I commit to raising or securing the funds needed for the specific team with which I am serving by the deadlines as laid out for that team.  I also understand that ALL money donated by me or those I contact is fully released by me and them to become a part of Jeremiah's Hope ministry fund.

I promise to demonstrate the the compassion and mercy of God and to show His love while serving on the team. 

My clicking the "SUBMIT" button is equal to my signature.  Please accept my application to be a part of the above mentioned team in Summer 2007!

Your application will not be complete until we have received your $20 non-refundable application fee.  The application fee does NOT count towards the cost of your trip.  The fee may be sent to:

Jeremiah's Hope, Inc.
PO Box 3411
Abilene, Texas 79604-3411

OR you can pay your fee online using our partner JustGive.org...to pay your application fee online, please go to our homepage and click on the JustGive logo.

If you have any questions, please contact us at: info@jeremiahshope.org