If Applicable

Must be an adult.

Additional references may be requested.

PLEASE NOTE that if you are accepted as a team member, a Physician's Release Form will be required prior to departure. Your Team Leader will inform you of this deadline. This information will be kept confidential unless it is needed for medical issues that arise on the trip.

Check the box if you would answer "Yes" to the question. Some of the questions are required in order to apply for this trip (indicated with a *). If you cannot answer "yes" to those required questions, we thank you for your time and ask you to not submit your application.

By typing my name below, I certify that all information on this application is accurate and complete. If I were to be approved as a team member, I am also giving consent for video/photos/audio that include my name, likeness, or voice taken by representatives of Mt. Horeb Church to be used for promotional purposes within the church, on printed and electronic media, and on electronic platforms, including but not limited to Mt. Horeb's website, official social media accounts, and digital media. In addition, I am agreeing to treatment by medical staff if an emergency arises while on this trip.

This is a copy of the Release and Waiver of Liability required to travel with Mt. Horeb. You may also be asked to sign a physical copy of this form prior to departure. By typing my name below, I recognize that there are risks involved in participating in the mission trip and hereby assume all risk of injury, harm, damage, or death in connection with my participation in it. I hereby acknowledge that by engaging in this mission, I am subjecting myself to certain risks voluntarily, including and in addition to those risks which I normally face in my personal and business life, including but not limited to such things as health hazards due to poor food and water, diseases, pests, and poor sanitation; potential danger from lack of control over local population; potential injury while working; and inadequate medical facilities, etc. I understand and agree that neither Mt. Horeb nor its trustees, officers, directors, employees, agents or representatives may be held liable in any way for any injury, harm, damage, or death that may occur to me as a result of my participation in this mission trip and hereby release Mt. Horeb, its trustees, officers, directors, employees, agents and representatives from any injury, harm, damage or death, which may occur while I am participating in the mission trip. To the fullest extent permitted by law, I agree to save and hold harmless Mt. Horeb, its trustees, officers, directors, employees, agents and representatives from any claim by myself, my estate, heirs, successors, assigns or other persons arising out of my participation in the mission trip. Further, I hereby release and discharge the mission organizations which assisted in these arrangements, their agents, employees, and officers, from all claims, demands, actions, judgments, and executions which I ever had, or now have, or may have or claim to have, against the mission organizations, their agents, employees, and officers, and their successors or assigns for all personal injuries to personal property, real or personal, caused by, or arising out of, the above described mission service. If I am unable to do so, I authorize Mt. Horeb through its trustees, officers, directors, employees, agents or representatives to consent to any necessary examination, anesthetic, medical diagnosis, surgery, or treatment and/or hospital care rendered to me under the general or special supervision and on the advice of any physician and surgeon licensed to practice medicine by the state or country in which they practice, during the duration of the trip.