Contact Information

Name *

Name

First Name

Last Name

Address *

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email *

Phone *

Phone

(###)

###

####

Emergency Contact Information

Name 1 *

Name 1

First Name

Last Name

Relationship *

Best Contact Number for Emergency Contact *

Best Contact Number for Emergency Contact

(###)

###

####

Previous Volunteer Service

Do you have previous volunteer experience with Lutheran Indian Ministries?

Yes

If you are a returning volunteer, in which community/communities did you previously serve?

When was your last volunteer trip with us?

Start date

YYYY

End Date

YYYY

Future Volunteer Service

How are you applying?

Individual

Member of a Team

If you are applying as a member of a team, list each person's name on the team.

-include yourself in this list **Note: Each member on a team must submit his or her own application.** Team Contact:

First Name

Last Name

Additional Team Members

I wish to serve as part of a:

Dates that you are available:

Ministry

Name of Congregation where you are a member

Congregation Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Congregation Phone Number

(###)

###

####

Congregation Email

Pastor's Name

First Name

Last Name

Pastor's Phone

if different than above

(###)

###

####

Please list the ministries you have been a part of in your church:

Personal

Your health is important to us while in the remote areas where we serve. Additionally, some volunteer situations will be challenging and strenuous. With this in mind, please rate your overall health:

Please note: Prescription medications CANNOT be refilled in the small communities where we serve. If you volunteer, you must bring enough prescription medication to last through your time of service.

Work History

List three employers, beginning with the most recent.

1.) Employer

Position

Dates of Employment

2.) Employer

Position

Dates of Employment

3.) Employer

Position

Dates of Employment

Volunteer Service

List three organizations with which you have volunteered.

1.) Organization

Position

Dates of Service

2.) Organization

Position

Dates of Service

3.) Organization

Position

Dates of Service

References

Please provide three personal references (pastor, teacher, co-workers, friends, etc.)

1.) Personal Reference

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Relationship to you

2.) Personal Reference

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Relationship to you

3.) Personal Reference

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Relationship to you

Authorization and Liability Release

By checking each box below, I am (or my guardian is) acknowledging that I have read the following information and agree to the standards set forth: *

I grant permission to the staff of Lutheran Indian Ministries to seek a National Criminal and Sex Offender record check.

I understand that Lutheran Indian Ministries may decline my volunteer participation based on the information received in such a background check.

I am at least 18 years old, or, as a minor, have the consent of a parent or guardian, and have, of my own free will, applied to volunteer for Lutheran Indian Ministries.

I consider myself healthy enough to fulfill my responsibilities during this volunteer service.

I understand I am engaging in this volunteer service at my own risk.

I understand that as a volunteer; a) I will not be paid for my services, b) I will not be covered by any medical or other insurance coverage provided by Lutheran Indian Ministries, and c) I will not be eligible for any Workers Compensation benefits.

I agree to refrain from using alcohol, marijuana, or other illegal drugs throughout my volunteer service.

I understand that bringing, carrying, and/or using weapons of any-kind (firearms, knives, explosives, any weapons considered lethal or dangerous) is prohibited on the premises and during my service.

I assume complete responsibility for personal injury and/or property damage that I sustain/cause during my participation as a volunteer. I agree that I, my assignees, heirs, guardians and legal representatives will not make a claim against Lutheran Indian Ministries or any of its affiliated organizations, its officers, directors, staff, agents, sponsors and successors collectively or individually for the injury or death to me or damage to my property, however caused, arising from my service.

Today's Date *

Today's Date

YYYY

Your Full Name (applicant) *

Date of Birth (required for persons under 18)

YYYY

Name of Parent or Guardian (required for persons under 18)

Electronic Signature

By checking the box below, you certify that all the information you provided on this application is complete and true. *

Yes, I have provided complete and true information.

Today's Date *

Today's Date

YYYY

Thank you for completing this application. All of the information secured in your application will be kept in the strictest confidence and will be used only for determing your volunteer service with Lutheran Indian Ministries. Once you have submitted your application, you will be redirected to complete a background check through a secure site, Protect My Ministry. Thank you for completing this mandatory background check!

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