Volunteer Registration Form

Please submit this registration form prior to each volunteer trip to West Africa. In the unlikely event of an emergency on the field, this information will be extremely helpful to the IMB personnel who are assisting you. We value your privacy and assure you that any confidential information will be treated with discretion. Thank you for your cooperation.

Personal Information

* First Name:		* Last Name:
* Address:		* City:	* State: * Zip:
* Phone:	Please use format 123-456-7890	Phone: secondary	Please use format 123-456-7890
* Email:

Church Information

* Church Name:
* Address:		* City:	* State: * Zip:
* Phone:	Please use format 123-456-7890
Pastor's First Name:		Pastor's Last Name:
Pastor's Email:

Emergency Information

We value your privacy and will only use this information in case of an emergency.

* Name of Emergency Contact in USA:		* Relation:
* Address:		* City:	* State: * Zip:
* Phone:	Please use format 123-456-7890	Phone: secondary	Please use format 123-456-7890
Email Address:
* What malaria prophylaxis are you taking?
List current medications and reason for taking:
List existing medical conditions, e.g. diabetes, epilepsy, allergies, etc:
Blood Type:

Insurance

* Adams & Associates Insurance Number:

Please enter "n/a" if you are not using A&A

Trip Details

Are you coming with an Engaging Church?

Arrival Date
in West Africa:

Departure Date
from West Africa:

Country(ies) you are visiting:
Hold down the CTRL key and
click to select multiple countries

	Arrival			Departure
#	City of Arrival in West Africa	Flight #	Time	City of Departure in West Africa	Flight #	Time
1
2
3
4
Click here to add another flight

* Name of missionary and/or people group(s) with whom you will be working:

Do you want to send a copy of this form to anyone, such as your team leader or your missionary contact on the field? If yes, enter their email address(es) below separated by commas:

Anti-SPAM

Due to SPAM issues we ask that you enter the word below into this field. If you can't read the word, click here to generate a new one.

Select:
Benin
Burkina Faso
Cameroon
Cape Verde
Central African Republic
Chad
Congo
Cote d'Ivoire
Equatorial Guinea
Gabon
Gambia
Ghana
Guinea
Guinea-Bissau
Liberia
Mali
Mauritania
Niger
Nigeria
Sao Tome and Principe
Senegal
Sierra Leone
Togo