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Mission Trip Registration

2023 South Africa | Campus Outreach CCCP

The team will be partnering with Campus Outreach Johannesburg to relationally engage college students with the Gospel.
6/5/2023 - 7/2/2023
$7,000.00
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Additional Information

All minors must have at least one parent present for each training.
*Gender
Please enter date of birth in format mm-dd-yyyy
*Date of Birth
If a minor, Grade (going into Fall 2022):
*In what country do you currently reside?
*Country of Citizenship
TSA Redress
PASSPORT INFO
*****Please enter your name exactly as it appears on your Passport.*****

*****If you DO NOT have a Passport, enter the name you will use when applying for your passport and enter “1” as your Passport Number.*****
*Passport First Name
Passport Middle Name
*Passport Last Name
Suffix
*Passport Number
*Expiration Date
EMERGENCY CONTACT
*Emergency Contact Full Name
*Relationship to Registrant
*Phone Number
CHURCH MEMBERSHIP INFO
*Perimeter Member Since (year)
*Perimeter Pastor's Name
*Perimeter Discipleship Leader Name
*Perimeter Activities
MEDICAL INFORMATION
*Do you have any medical conditions or take any medications which your team leader may need to be aware of as you participate on this journey?

If your response is yes, the GO Journey Coordinator will contact you to discuss how we can best accommodate your needs.
APPLICATION QUESTIONS
*Share a short summary of your spiritual journey.
*Describe any cross-cultural ministry experiences
*Describe what you hope to see the Lord do in and through you on this journey
*Who was the most influential in your decision to participate in a GO Journey?
GIFTS
Spiritual Gift 1
Spiritual Gift 2
Spiritual Gift 3
SKILLS
Skill 1
Skill 2
Skill 3
Other Skills
SAFETY FORM
The questions below are part of the process to help provide a safe and secure environment for our children.  We understand that the answers to these questions may be private and deeply personal, and we will protect your privacy.
*Have you had any experiences that might make it difficult for you to minister to children/youth :
*Are you currently using illegal drugs:
*Have you ever participated in, or been accused of, convicted, pleaded guilty, or pleaded “no contest” to any criminal offense of any kind:
*Have you ever participated in, or been accused of, convicted, pleaded guilty, or pleaded “no contest” to any sexual misconduct act or allegation involving a child:
*Have you ever participated in, or been accused of, convicted, pleaded guilty, or pleaded “no contest” to any physical or emotional abuse of/to a child:
*Do you struggle with any significant negative childhood experiences, including physical or sexual abuse, that you have not yet processed in a healthy manner:
*Have you experienced any significant physical or emotional stresses within the past year, such as the loss of a parent, spouse, or child; extreme ill health; or any emotional or physical crisis:
*Have you ever been denied legal custody of your child(ren) in any legal proceedings including divorce decrees or settlements:
*Are you aware of any traits or tendencies you possess that could pose any threat to children, youth, or adults with disabilities:
*Do you have any health issues that could place children at risk:
If you answered Yes or Unsure to any of the questions above in the Safety Form section and/or if there is anything else that we need to be made aware of, please explain. 
:
Please submit references that are familiar with your character and are deemed helpful in allowing Perimeter to determine fitness for position. The references should be familiar with the quality of your work and your character.  One of these references should be a person of the opposite sex.  All references should have known you for at least 6 months and be age 18 or older.  (If you are a minor, one reference can be a peer-age friend if need be, one parent, and one other adult (ministry/discipleship leader, teacher, coach, etc.)  
*Reference 1: Close Personal Friend:
*Reference 1: City and State of Residence:
Reference 1: Telephone:
*Reference 1: Email Address:
*Reference 2: Close Family Member:
*Reference 2: Relationship:
*Reference 2: City and State of Residence:
*Reference 2: Telephone:
*Reference 2: Email Address:
*Reference 3: Professional Co-worker/Ministry Leader/Perimeter Staff Member:
*Reference 3: Relationship:
*Reference 3: City and State of Residence:
*Reference 3: Telephone:
*Reference 3: Email Address:
:
:
*I declare that all statements above are true. I understand that any misrepresentation or omission is cause for dismissal from any program involvement.:
*I understand that Perimeter Church has a policy of ZERO TOLERANCE FOR ABUSE and takes all allegations of abuse seriously.   I further understand that Perimeter Church cooperates fully with the authorities to investigate all cases of alleged abuse.  Abuse of any kind is grounds for immediate dismissal from my volunteer position and may result in criminal charges.
*I am not a pedophile or child molester.  I have not perpetrated physical abuse, sexual abuse, emotional abuse or neglect against a child, student or disabled adult, and I have never been accused of these acts.
*I understand and agree that false statements regarding past conduct and/or present situations may be grounds for termination of any volunteer position, and failure to reveal the contents of a sealed criminal record will result in the automatic denial of the application and opportunity to serve as a volunteer.
Please review and sign the Release Statement
I authorize Perimeter Church to contact all individuals, organizations, and references listed on the Application and Safety forms in order to verify the information I have provided.  I agree to release from liability any person or organization that provides information related to me, including those persons I have listed as references, as well as contact persons from my previous volunteer work or employment with children. I specifically authorize Perimeter Church to undertake a criminal background check concerning my past. I understand and agree that any information received from the background check and application verification may not be disclosed to me except as required by law, and I hereby waive any right I may have to inspect any information provided about me by any person or organization identified by me on this form. By signing this form below, I certify and affirm that the information I have given on this form is true, complete and correct in all respects.
*Signature Name:
*Signature Date:
Please click 'Next' only once.  Do not click back to this page or you will be registered multiple times.