Welcome To Christian Hands In Action!

PCA Family Missions Application
	If you woud like to print a PDF version of the application please click the logo on the left.
Mission Information
Village/Site:
Starting Date:	January 17, 2010

General Information
Prefix:
Parent(s) First Name:
Last Name:
Attending Children (age) :
Address:
City, State:
Zip:
Country:
Telephone:
Mobile Telephone:
E-Mail:

Personal Information
Main Contact Gender:	Male Female
Occupation:
Marital Status:	Single Married
Spouse Name:
T-Shirt Size (Qty):	M L XL XXL XXXL

Travel Information
Departing Airport:
Citizenship:
Date of Issuance:	(Passport)
Date of Expiration:	(Passport)
Main Contact Date of Birth:
Place of Birth:

Field of Ministry
Previous CHIA Mission:	Location: Date:
Are you a Pastor or Preacher? Yes No
Are you willing to do a Devotional: Yes No
Foreign languages:
Proficiency:	Excellent Good Fair Cloudy
Do you sing?:	Yes No
	If yes, would you on this Mission Yes No
Special Skills (Balloons, Guitar, etc.)

Medical/Emergency Information
Any health problems?	Yes No
If Yes, please describe:
Current Medication(s):
Diseases/Allergies:
Sleeping Conditions: (snoring, insomnia, etc)
Emergency Contact #1 (not traveling with you)
Prefix:
Name:
Address:
City, State:
Zip:
Country:
Telephone:
Mobile Telephone:
Emergency Contact #2 (not traveling with you)
Prefix:
Name:
Address:
City, State:
Zip:
Country:
Telephone:
Mobile Telephone:

Ministry Information
Home Church :
Pastor:
Address:
City, State:
Zip:
Country:
Telephone:

How did you find out about CHIA?
1 of 4 pages