Volunteer Registration Form

Please submit this registration form prior to each volunteer trip to 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:
* Church Emergency Contact:	An individual that can be contacted at your church in case of an emergency	*Church Contact Phone:	Please use format 123-456-7890
* 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

* Gallagher Insurance Policy Number:	Please enter "n/a" if you are not using Gallager
* Gallagher Insurance Enrollment Number:	Please enter "n/a" if you are not using Gallager
Toll free number (800) 922-8438

Trip Details

Arrival Date
in country:

Departure Date:

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

	Arrival			Departure
#	City of Arrival in Africa	Flight #	Time	City of Departure in 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:

Email of your missionary contact on the field and any other email address you wish to send this form to. Please 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:
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Comoros
Congo
Cote d'Ivoire
Equatorial Guinea
Gabon
Gambia
Ghana
Guinea
Guinea-Bissau
Kenya
Lesotho
Liberia
Madagascar
Malawi
Mali
Mauritius
Mayotte
Mozambique
Namibia
Niger
Nigeria
Reunion
Rwanda
Saint Helena
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
South Africa
Sudan, South
Swaziland
Tanzania
Tanzania Islands
Togo
Uganda
Zambia
Zanzibar
Zimbabwe