Missions Registrations Name * First Name Last Name Address Phone Number (###) ### #### Email Small Group or Cohort Leader Name First Name Last Name Emergency Contact Name First Name Last Name Emergency Contact Phone Number (###) ### #### Emergency Contact Relationship Missions Experience List missions trips you’ve been a part of, whether foreign or domestic, when you went, and which agency or church you went with. Medical Do you have any allergies or take any medications? Any other medical circumstances? If so, please list them so your team leader can adequately take care of you during the trip. Testimony Please type out your testimony in the space below. Please be short, but specific and detailed. Additional Info Is there anything else the Chi Alpha staff or team leaders should know before placing you on a team? Fundraising Are you willing to ask friends, family, coworkers, fellow students and other people for financial support in order to go? Why or why not? Skills Do you have any special skills, talents, or hobbies? Do You Have a Passport? Yes No Are you planning on applying for the Chi Alpha Internship (CMIT) for the 2024-2025 academic year? Yes No Are you planning on applying to serve with World Missions or Chi Alpha full time starting in 2024? Yes No Trip Preference #1 Please choose the trip you'd most like to go on Gunnison Russia Pennsylvania Indonesia Trip Preference #1 Reason Please explain why this is your top trip choice Trip Preference #2 Gunnison Russia Pennsylvania Indonesia Trip Preference #2 Reason Trip Preference #3 Gunnison Russia Pennsylvania Indonesia Trip Preference #3 Reason Thank you!
