Survey - Application - Mission Teams - Orthodox Christian Mission Center

PERSONAL INFORMATION

1.

Please provide your contact information below:


	Title:
*	First Name: Required
*	Last Name: Required
*	Email: Required
	Street 1:
	Street 2:
	City:
	State / Province:
	ZIP / Postal Code:
	Country:
*	Phone Number: Required
*	Gender: Required
*	Date of Birth: Required	Date of Birth:
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*2.

Question - Required - Gender
Please make 1 selection from the choices below.

	Male
	Female

*3.

Question - Required - Date of Birth:

Month

Day

Year

4.

Question - Not Required - Marital Status:

5.

Question - Not Required - If Married, Spouses Name:

6.

Question - Not Required - Do you have a valid Passport (must be valid at least six (6) months upon expected return date):

7.

Question - Not Required - Name as it appears on Passport:

8.

Question - Not Required - Passport Expiration Date:

Month

Day

Year

CHURCH INFORMATION

9.

Question - Not Required - Parish:

10.

Question - Not Required - Jurisdiction:

11.

Question - Not Required - Priest:

12.

Question - Not Required - Email (Priest or Parish):

*13.

Question - Required - Parish Address:

(Maximum response 255 chars, approx. 5 rows of text)

TEAM PREFERENCE

14.

Question - Not Required - Please select 1st choice Team preference:

15.

Question - Not Required - Please list 2nd choice Team preference (alternate):

EMPLOYMENT, EDUCATION AND LANGUAGE

16.

Question - Not Required - Current Occupation:

17.

Question - Not Required - Employer Name:

18.

Question - Not Required - Length of Employment:

EDUCATION

19.

Question - Not Required - Degree(s) Earned - include Institution, (list degrees, certificates, titles, year graduated):

LANGUAGE SKILLS

20.

Question - Not Required - Language(s) spoken, and degree of fluency (i.e. beginner, conversational, advanced, etc):

(Maximum response 255 chars, approx. 5 rows of text)

EXPERIENCE

21.

Question - Not Required - Have you ever participated in Evangelism?

22.

Question - Not Required - Do you have Teaching experience?

23.

Question - Not Required - Have you ever been involved in Youth ministry?

24.

Question - Not Required - Do you have ministry experience (evangelism, teaching, youth ministry, other) that would help in the mission you are applying for?

(Maximum response 255 chars, approx. 5 rows of text)

25.

Question - Not Required - List any other talents, interests, skills (arts, sports, technical, construction, other):

(Maximum response 255 chars, approx. 5 rows of text)

MISSIONS QUESTIONS

26.

Question - Not Required - Briefly describe your life in Christ.

27.

Question - Not Required - How are you involved in the Church?

28.

Question - Not Required - Why would you like to be a part of an Orthodox mission?

EMERGENCY CONTACT

*29.

Question - Required - Name:

*30.

Question - Required - Phone Number:

*31.

Question - Required - Email:

*32.

Question - Required - Address:

33.

Question - Not Required - Relationship to you:

HEALTH INFORMATION

34.

Question - Not Required - Height (ft', in"):

35.

Question - Not Required - Weight:

MEDICAL HISTORY

*36.

Question - Required - Have you been hospitalized in the past 5 years?

37.

Question - Not Required - If yes, describe nature of issue(s) and date(s):

(Maximum response 255 chars, approx. 5 rows of text)

*38.

Question - Required - Do you have any chronic health conditions (please include hypertension, diabetes and any other medical conditions that require regular medication) ?

*39.

Question - Required - Have you had surgery (other than tonsillectomy, hernia repair, appendectomy or wisdom teeth removal)?

*40.

Question - Required - Are you under the care of a doctor or other practitioner for any reason?

41.

Question - Not Required - Have you been treated by a professional to address emotional or behavioral difficulties, or received psychological counseling or therapy?

*42.

Question - Required - Have you been hospitalized for a psychological problem in the past five years?

43.

Question - Not Required - For everything checked "yes", describe the nature of the issue, surgery, treatment, and dates:

44.

Question - Not Required - Please describe other restrictions, or special dietary needs:

(Maximum response 255 chars, approx. 5 rows of text)

ALLERGIES

45.

Question - Not Required - Are you allergic to any medicines (penicillin, sulfa, etc), insect stings, foods, animals or plants?

46.

Question - Not Required - List all allergies and specific reaction (example: penicillin (rash), peanuts (itching), bee sting (anaphylaxis):

(Maximum response 255 chars, approx. 5 rows of text)

MEDICATION

47.

Question - Not Required - List medications, dosage, and condition it was prescribed for.

(Maximum response 255 chars, approx. 5 rows of text)

STATEMENT OF CONSENT

The Orthodox Christian Mission Center (OCMC) may contact my parish priest, spiritual father, and references I provide, and /or any organization/institution/affiliation that may have relevant information about my qualification to serve on a mission. I authorize and release from liability such persons and agencies to provide information and background verification as requested by OCMC in order to complete the processing of this application. I acknowledge that all my required vaccinations are up to date, and I assume full responsibility for any additional immunizations that may be required in the country/region of my mission service. I authorize OCMC to retain and rely on this application, and to obtain additional information as needed for my participation in a mission. I understand that OCMC will maintain all information in privacy and confidence, limiting its release only to parties involved with the facilitation and implementation of the OCMC Mission assignment.

*48.

Question - Required - I am aware that my participation on an Orthodox Mission will be voluntary. I clearly understand that, if I am accepted, raising all expenses will be my responsibility. I further agree, if selected, to conduct myself in a manner befitting an Orthodox Christian rendering service to the Church and Our Lord, Jesus Christ. I also certify that to the best of my knowledge, all information in this application is accurate and complete.