Belize Registration Form

Please fill out the form. Please note, you are not 100% registered until we recieve your non-refundable deposit of $200 and all of your completed paperwork. Forms are also available in the Outreach Office.

The paperwork required is:

- Registration Form (either fill out below or download here)

- Health History Form (Click to download)

- Copy of Front and Back of Your Health Insurance Form

- Release Form (Click to download)

- Signed Covenant (Click to download)

Please contact the Outreach Department for information. Please submit a separate application for each participant.

Last Name*
First Name*
Exact Name on Passport*
Passport Number*
Expiration Date* (Format: mm/dd/yyyy)
Passport Country*
Birthdate* (Format: mm/dd/yyyy)
Place of Birth*
Marital Status



T-shirt size*
Mailing Address*
City*
State*
Zipe Code*
Primary Phone*
Mobile Phone
E-mail Address*
Place Of Employment*
Work Address
Job Title
In the event of emergency, please notify (person not going on Mission Trip):
Name:*
Relationship*
Address*
Phone Number*
Alternative Phone Number*

I agree to pay the $150 non-refundable deposit before the deadline of November 7.
I agree*

I will use the following credit/debit card to pay the deposit.  I understand and agree to pay the 3-5% interest payment charged to the church to use my credit card:
Card:
Card Number:
Expiration (MM/YY):
 

I agree to submit all required paperwork and payment by the above dates.  I understand that I will not be able to go on the trip if I do not have my completed Health History Form to the Outreach office by January 1, 2008.  I have read the Mission Trip Covenant. I agree to serve as a member of the team. By submitting this application, I commit to full participation. 

I certify that all information I have supplied in this application is true to the best of my knowledge.
I Agree*

 
Electronic Signature (Please fill in Name)*
Comments: