CAMBODIA SHORT TERM TEAM

APPLICATION FORM.

I am applying for the Cambodia Team

General Information.

Your Name:

Your Telephone Number:

Your Email Address:

Postal Address:

Age:                     Nationality:

Marital Status:   Spouse's Name:

Please contact me by: Email Telephone  Mail 

Emergency Contact

Name:

Relationship: 

Mobile Phone:  Home Phone: 

Address: 

Medical Information

Date of last tetanus inoculation:

I have or will contact my Dr in regards to required vaccinations. 

List any medications you are allergic to. 

List any medications you are currently taking. 

Do you have any conditions that would restrict you on your ministry trip?  Describe:

How do you rate your present heath condition? 

Church Affiliation

Church Name: 

Pastors Name: 

Contact (email or phone): 

Will you agree to wear culturally appropriate clothing?  Will you agree not to use

tobacco, illegal drugs, or drink alcoholic drinks while on the team?YES NO 

Release of all claims, waiver of liability, assumption of risk,

and indemnification agreement

Overseas mission trips, by their very nature, offer an unfamiliar and unique environment, and risks of injury to both persons and property are possible.  I understand that by my participation in a short term mission experience, I am indicating my acceptance of these risks.

In consideration of my being accepted by OMS International Australia Inc., for a short term missions experience, I   hereby voluntarily release OMS International Australia Inc., and each of its employees, trustees, officers and agents from all potential liability resulting from personal injury or property damage incurred by me as a result of the negligent or other acts or omissions of OMS International Australia Inc., its agents or employees.

I further agree to indemnify OMS International Australia Inc., and each of its employees, trustees, officers and agents for any expenses or costs resulting from these acts or omissions or resulting in any way from my participation in an OMS International Australia Inc., short term missions experience, including my own negligence.  I am aware that I need to arrange my own travel insurance, but that this insurance may not cover all situations.

Agree: 

Adult authorisation and consent to emergency medical treatment

In case of a medical emergency, I hereby give OMS International permission to authorise emergency care by a physician as he or she may deem necessary or I give my permission for my son/daughter to be part of the OMS International team.  Also I give permission for my son/daughter to be transported to the team location.  In addition, I give permission for my son/daughter to receive any emergency medical treatment deemed necessary by a physician.

Agree: 

If giving permission on behalf of your son / daughter - Your Name : 

Confirmation

To confirm application send -

- a copy of your passport,

- one colour photo, 

- $200 deposit  (Refundable if not accepted or if the trip is cancelled)     

to OMS International, PO Box 897, RINGWOOD, VIC 3134.

Deposit may be paid by cheque or direct deposit to our bank account:Westpac Bank, OMS International, BSB 733172 # 628724 (please put your name and 'Ukraine deposit' into the transaction details.