Thank you for your interest in the mission trip to Brazil for 2025.

Please provide all the information requested in the form below.

God bless you.

PERSONAL DETAILS

Title *

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Name *

First name *

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Middle name(s)

Surname *

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Email *

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Mobile *

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Date Of Birth *

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Nationality *

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Passport Number *

(needed when securing your accommodation and flight)

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Passport Expiry Date *

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Relationship Status *

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If married, name of spouse

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Is your spouse a member of New Wine Church? *

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FRIEND / LOVED ONE - based in the UK (to be contacted on your behalf)

Full Name *

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Address *

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Address

Address 1

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Address 2

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Address 3

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Town

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County

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Postcode

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Country

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Phone (Daytime)

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Phone (Evening)

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Email Address

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SPIRITUAL LIFE

Have you received Jesus Christ as your Lord and Saviour? *

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Are you a member of New Wine Church? *

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YOUR HEALTH

Do you have any physical or emotional illnesses that could affect your experience on this trip? *

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If yes, please provide brief details, including any treatment you are receiving, and how we can support you.

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Do you have any allergies? *

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If yes, please specify

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Are you currently on any medication or receiving therapy or counselling for any condition? *

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If yes, please provide details.

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YOUR PASSPORT

Will you be travelling with a British Passport? *

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If no, please specify which passport

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TRAVEL INSURANCE

Do you have any preference in terms of travel insurance? *

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If yes, please specify.

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REFERENCE - LEADER DETAILS

Full Name *

First name *

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Middle name(s)

Surname *

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Address *

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Phone Number *

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Email Address *

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How many years has the leader known the applicant? *

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REFERENCE - CHARACTER

Full Name *

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Address *

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Phone Number *

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Email Address *

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How many years has the referee known the applicant? *

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CONFIRMATION

I confirm my interest in going to the Mission Trip to Brazil in 2025 *

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PAYMENT PLAN

How do you plan to pay your deposit? *

If by Telephone, call 020 88 555 888

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How do you plan to pay the balance for your trip? *

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Thank you for providing the required information. A member of our team will contact you soon.