Team Member Application Form

* Denotes a Required Field

Basic Information

 I'm applying to be a team member along with others from a church or university. l'm applying as an individual to become a distanced team member to be placed with a team.

If you are applying to join a team from a university, please specify:

If a college or university student I currently attend:

If you are applying as an individual, you may optionally specify a team you would like to join:

I attend (name of church):

Sessions: All dates given are approximate and can vary:
 I can be available for any session between June 1 - Aug 5 Session 1: Early June Session 2: Late June - Mid July Session 3: Mid July to Early August

Personal Information

*Full legal name as it appears on passport:

*Preferred name:

*Address (if college student: your college address is okay):
Line 1:
Line 2:

*City:     *State:     *Zip:

Phone:
Cell:     Landline:     Work:

*Your Email:

*Birth Date:     *Age:

Marital Status:
 Single Married Divorced Widowed

Spouse's Name:

*Your Occupation:

*Current or Most Recent Job Title:

Passport Number:     Passport Expiration Date:
Note: If you are uncomfortable sending this information online, please call our office to provide this via phone after you have completed the application

*Closest regional and international airport for your departure:

T-Shirt size:
 Small Medium Large XLarge XXLarge XXXLarge

Experience

Do you have domestic or international missions experience?
 Yes No

If yes, please specify the dates, purposes, and locations of each mission:

Do you have recent experience in teaching or working with children?
 Yes No

If yes, please specify ages of the children you worked with and what you did:

General Questions

Describe your temperament and work style:

What is your personal goal for this mission trip?

Describe how you would work in a situation that may include: communication boundaries, unsanitary conditions, limited food options, uncomfortable sleeping conditions, last minute schedule changes, etc.:

Are you willing to make changes in personal habits or dress to avoid being offensive in a foreign culture or to your team?
 Yes No

Are you willing to attend and participate in team meetings regularly (there will be approx. 12)?
 Yes No

lf you are applying as a distanced team member, are you willing to be available for online or phone participation with your team in their team meetings and discussions?
 Yes No

Are you willing to abide by the spirit and mission/intent and policies of By Example Youth Missions?
 Yes No

Are you willing to attend Team Training? Team training consists of 2 days' meeting on one weekend in March.
 Yes No

Where did you hear about BEYM Youth Camps?
 Presentation from an BEYM representative From someone who worked in a camp From exploring the website Other:

Spiritual Survey

*When did you become a Christian?

*Please describe your personal walk with the Lord at this time:

*Please share some of your personal ministerial strengths as they would relate to this trip:

*Please share some of your personal ministerial weaknesses as they would relate to this trip:

Physical Assessment

Do you have any limitations related to walking or mobility?  Yes No

If yes, please explain.

Do you have any medical conditions for which you are currently receiving treatment?  Yes No

If yes, please explain.

Do you have any physical limitations or disabilities?  Yes No

If yes, please explain.

Are you physically able to carry two large pieces of luggage (up to 50 lbs each) into my accommodations without the assistance of an elevator?  Yes No

Are you presently being treated for any mental or emotional conditions?  Yes No

If yes, please explain.

Are you currently taking any medications?  Yes No

If yes, please list them.

Physician's Name:

Physician's Phone Number:

Personal References

Please list 2 references. It is your responsibility to provide your 2 references with a printed BEYM reference form from this site or with instructions for accessing the online reference form from this site. BEYM will not contact these names about receiving your references. Each reference needs to be an unrelated/non- family member who has known you for at least 3 years. One reference needs to be filled out by a church minister or church leader and the 2nd by an employer, co-worker, professor, or friend.

*Name:     *Relationship to you:

*Name:     *Relationship to you:

Emergency Contacts

Next of Kin:
*Name:     *Phone:     *E-mail:

Emergency Contact #2:
*Name:     *Phone:     *E-mail:

Hold Harmless Agreements

AGREE TO RELEASE, HOLD HARMLESS AND INDEMNIFY FROM ANY AND ALL CLAIMS ASSERTED BECAUSE OF ANY INJURY TO MYSELF, By Example Youth Missions, all of its affiliates, and all individuals, named and otherwise, participating with the explicit approval of the duly authorized representative of By Example Youth Missions, including but not limited to volunteers, from any and all damages arising during the period of my participation in the BEYM Youth Camp Program as I travel to Ukraine and am at youth camp and then return from camp to the United States. I do hereby agree to hold By Example Youth Missions harmless and agree to indemnify fully By Example Youth Missions for any and all judgments and damages rendered against it and including costs, attorney's fees, regardless of whether or not there is litigation and including mediation and arbitration proceedings which result from or that are in any way connected with monetary, physical, mental, emotional or other type claim of injury to me that is claimed or asserted.

 I have read and agree to the above terms.

*Acknowledgement

 I understand that I am responsible for contacting my 2 references about submitting reference information. If accepted to serve as a Youth Camp team member, I understand that I am responsible for providing or raising the total amount of funds required by each team member. I am aware that a background check will be run on me. I understand that if I'm unable to participate this year, my application and application fee can be held for future BEYM youth camps, but it is non-refundable. I agree to demonstrate a Christ-like attitude and will act in cooperation with the guidelines set by BEYM in order to honor God. If my application is not accepted my application fee is non-refundable. I acknowledge that all information is current and correct.

*Electronic Signature:


Note: Typing your name into the box above legally serves as your signature for this electronic form.

*Today's Date:

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