2012 Form - Christadelphian Meal-A-Day of the Americas Service Project

2012 Application Form for the CMaDFA Service Project

1. Basics

Name
Date of Birth
Email
Phone Number
Physical Address
Mailing Address (if different)
Home Ecclesia
Are you baptized?	Yes No
Gender	Male Female
Marital Status
T-Shirt Size (e.g.: Male XL, Female M)

2. Health Information

Current Health Status
(Please include significant past/current health or emotional health issues, medications/dosages you currently take, etc.)

Allergies and/or Special Dietary Needs
(If you have allergies please describe previous allergic reactions and severity. (epi pens, need for benadryl etc.))

Medical or Emergency Contact's Info

Name
Relationship
Phone Number

3. Passport

This must expire after February 15, 2013. If you do not have one you must be willing and able to get one before you purchase your tickets.

Do you have a Passport?	Yes No
Country
Expiration Date

4. References

You will need two letters of reference from mature Brothers or Sisters in good standing (non-family members) which should address both your strengths and anything they think might be a challenge for you on this project (socially, physically, emotionally, spiritually). Have them email these directly to nicabuild2012@gmail.com. Your application can not be considered until these arrive, and your application does not meet the deadline if a reference is still missing at that time.

First Reference's Name
First Reference's Role in the Ecclesia
First Reference's Email
Second Reference's Name
Second Reference's Role in the Ecclesia
Second Reference's Email

5. Preparation for Service

What other skills or experience do you have that may be helpful to the project or team?
Nursing	Spanish	Computer
Success on a team	First Aid Responder	Musical instrument

Current Employment or School Status
(what are you doing with your life these days?) What serving experience do you have/ what things are you currently involved in supporting in your home ecclesia? Please provide your thoughts regarding your current spiritual life Why do you want to be a part of this Meal a Day Build 2012 (what do you expect to gain from this experience)? Do you speak Spanish? (Very Fluent, Fluent, Moderately Fluent, Not Fluent, None) Will hard work, in a daytime temperature up to 90 degrees, in direct sunlight or rain be a problem for you? If you are married or a parent, how does participating in this project impact your family? Where appropriate, please also have your spouse add a paragraph here as to how he/she understands the potential impact to the family routine, and how any possible difficulties will be overcome. Please list two or three ways you may fundraise your trip. Are you certain you will be free of other obligations during the dates of these Build trips? What other help or special consideration do you think you may need to prepare for and participate in this project? How would you resolve frustrations you experience during the trip? Have you participated in any other service/missions experiences for or outside of your home ecclesia in the past? What is your travel experience? How do you see yourself serving the team during this trip?

I have read and agree with the statements here