Institute for the Nations Youth With A Mission – Sunshine Coast Mission Builders Application Form

Page 1

PART 1- Personal Details
You are Applying for: MISSION BUILDER

Name: (write your name as found in passport)
Contact Info 

Emergency Contact (Who do we need to contact in case of an emergency)

Birth Details


Passport Details

Page 2

Part 1- Personal Details (continued)







Medical History

Please answer all questions. Comment on all positive answers at the end of this form or on a separate sheet.

Have you ever had any of the following?

































Page 3


Have you ever had any of the following?

Allergy
Surgery

Females Only
Are you at present under a Doctor's care for any condition?
Are you taking any medication at this time?
Please provide details of any positive answers and give details of any other illnesses you have had.


Part Two– Release of Liability & Other Declarationslick here to enter a heading


Release of Liability

I do hereby release Youth With A Mission INC, its agents, employees and volunteer assistants from any liability
whatsoever arising out of any injury, damage or loss which may be sustained by said person during the course of
involvement with Youth With A Mission.

Consent for Treatment

I hereby agree to the performance of such treatment, anaesthetics and operations as in the opinion of the attending
physician if deemed necessary on.

Consent for Burial

I agree that, in the case of my death while with Youth With A Mission, Youth With A Mission may carry
out the burial in the place of the deceased. If my family desires to have my body shipped home, my
family will pay for it. I hereby absolve Youth With A Mission and all its staff and associates of any burial
costs.






Youth With A Mission Sunshine Coast
PO BOX 5633 MAROOCHYDORE QLD 4558 AUSTRALIA
Phone: (07) 5479 0580 Fax: (07) 5479 0380 Email: admin@ywamwaves.com Web page: www.ywamwaves.com