Record Entry-Edit | Power Ministry

Trip Edit Form

for Dave Coryell

Participant Infomation

First Name you go by*
Last Name*
First Name*	As it appears on government ID
Middle Name	Required for airline tickets and those wishing to be drivers
Address*
City*
State*
Country
Zip Code*
Cell Phone*	###-###-####
Home Phone	###-###-####
Work Phone	###-###-####
Email*	Must be unique to Power. Not the same as another Power member.

Personal Information

Birthday*	mm/dd/yyyy
Wife's First Name
Anniversary	mm/dd/yyyy
Church you attend*
Occupation
Hobbies, Gifts, Talents, Expertise, other Interests	too many to list them

Trip Related Information

Shirt Size*
Are you willing to visit a prison?	Are you willing to visit a prison? Yes No Either
Do you play guitar or keyboard?	Do you play guitar or keyboard? Yes No
If yes, would you be willing to play with worship team if needed?	If yes, would you be willing to play with worship team if needed? Yes No
Are you a pastor?	Are you a pastor? Yes No
Are you willing to lead prayer?	Are you willing to lead prayer? Yes No
Are you willing to pray out-loud?	Are you willing to pray out-loud? Yes No
Do you have a passport?*	Do you have a passport? Yes No Applied For A passport is a MUST
Passport Expiration Date	The expiration date must be at least 6 months after the end of our trip.
Are you interested in being a van driver?	Are you interested in being a van driver? Yes No Either

Driver Information

For those wishing to be drivers please complete the following section, All information is required:

Driver License Number
License Class
Commercial Driver	Commercial Driver Yes No
License State
License Expiration Date	mm/dd/yyyy
Are You Married	Are You Married Yes No
Medical issues	Medical issues Yes No Are you aware of any condition that may affect your vision, hearing, perception, reflexes, flexibility, or judgment?
Medication	Medication Yes No Do you take any medications that warn against driving/operating equipment?
If your answer is YES to any of the above questions please explain each occurrence
Have you attended a Traffic Safety Course?	Have you attended a Traffic Safety Course? Yes No
Have you ever been convicted of a criminal offense?	Have you ever been convicted of a criminal offense? Yes No
If your answer is YES please provide the date and description of each conviction

	Check the vehicles you have driven in the past:
Bus
Heavy Truck
Tractor Trailer

Skills You Have

General Construction
Electrical
Drywall
Plumbing
Carpentry
Roofing
Heating and AC
Painting
Handyman
Automotive
Electronic
Sports
Strong Lifter
Organizer
Photography
Videography
Computers
Web
Writing
Spanish
Medical Knowledge

Power Involvement

If so, where?	Reynosa, El Shadai
Have you ever been on a missions trip besides a POWER trip?	Have you ever been on a missions trip besides a POWER trip? Yes No
How did you hear about POWER?	bridges & power guys

Medical Information

Emergency contact person*
Contact relationship*
Contacts phone number(s)*	###-###-####
Medical insurance company*
Date of last tetanus shot*
List physical limitations if any:	Strained Back, compressed disk
List allergies if any:	Mountain Cedar
List medical disorders if any:	Diabetic (type 2), High BP
List special medication if any:
List special nutritional needs if any:

Verifiy

I have verified all my information*

	Please be sure all information is correct and up to date before proceeding.