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. .. .. .. .. .. ..		Footsteps Trip Application Please fill out this application as completely as possible. * indicates required information. Security The password is used to edit registration if needed after you have submitted it. It can also be used to track your support through Support Tracking. Please keep the password safe. *Password *Re-enter Password Personal Information *First Name (As it appears on passport) Middle Name (As it appears on passport) *Last Name (As it appears on passport) Street Address 1 Street Address 2 Street Address 3 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Age *Birthdate (YYYY-MM-DD) Gender Male Female Marital Status Single Married Occupation Home Phone Number Cell Phone Number Work Phone Number Fax Number E-mail Address Citizenship Passport Number If you do not have a passport, please see US State Department for more information. Passport Expiration Date (YYYY-MM-DD) Trip Information *Trip Destination Costa Rica - Ellensburg Alliance Church (Feb 2009) Costa Rica - Footsteps Trips for Universities (May 2009 - Jun 2009) Costa Rica - Olivet Nazarene University (May 2009 - Jun 2009) Honduras - Olivet Nazarene University (Mar 2009) Honduras - Footsteps Trips for Universities (May 2009 - Jun 2009) Israel, Jordan & Egypt - Footsteps (Oct 2009) Romania - Footsteps Trips for Universities (May 2009 - Jun 2009) Romania - Olivet Nazarene University (May 2009 - Jun 2009) South Africa - Footsteps Trips for Universities (May 2009 - Jun 2009) South Africa - Olivet Nazarene University (May 2009) South Korea & China Cross Cultural Camp - Footsteps Trips for Universities (Jul 2009 - Aug 2009) South Korea & China Cross Cultural Camp - Olivet Nazarene University (Jul 2009 - Aug 2009) South Korea, Seoul - Footsteps (Jan 2009) Thailand - Olivet Nazarene University (May 2009 - Jun 2009) Thailand - Footsteps Trips for Universities (May 2009 - Jun 2009) USA Cross-Cultural Camp (California) - Olivet Nazarene University (Jul 2009) If not found, please specify the country and month of the trip below: Roommate Request Church Membership Future Interest Country Is there a country you are interested in serving in the future? *Shirt Size Youth 14-16SmallMediumLargeX LargeXX Large For groups getting a Footsteps shirt, please enter your shirt size. Insurance Information Insurance Carrier Group Number (If Applicable) Member Number (If Applicable) Phone Number Fax Number   Emergency Contact *Name *Phone Number (000-000-0000) *Relationship SpouseFatherMotherSisterBrotherFriendSonDaughterGrand MotherGrand FatherCo-WorkerOther RelativeOther Health Information Please describe any health limitations that may require supervision: Do you require any medication? If yes, please describe your condition and the medication type. Immunization & Vaccination For recommended vaccination, see the Center for Disease Control for the country you are going to. Service Experience What is your primary motivation for participating on this trip? Please describe any prior servie you have done in the past. Please describe any language training if applicable.  List the language, duration of the study and type of study. List  any other areas of christian service if applicable. (For example, sunday school teacher, youth leader, etc.) Do you sing? If so, which parts? Do you play an instruments? If so, which ones and for how long? Do you have any other talents or gifts that you think may be of assistance on this trip?
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