Team Name

Contact Name  

Ministry Position Pastor Youth Pastor Individual Choir Director Ministry Director / Leader Small Group Leader

Street Address  

City   State AL AK AZ AR CA CO DC CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY   Zip

Contact Phone

E-mail

Fax   Home Phone

Proposed Ministry Dates

Alternate Dates

Approximate Number of People 1 to 5 6 to 10 11 to 15 16 to 20 21 to 30 31 to 40 41 to 50 51 to 60 61 to 70 71 to 80 81 to 90 91 to 100 100+

Will you bring a van for ministry?  Yes No Unknown

Please contact me by:  Phone  E-mail  Fax

I am interested in the following:  (Check all that apply)
          January Compassion Outreach Weekend 
          February Compassion Outreach Weekend
          March Compassion Outreach Weekend
          Spring Break Outreaches (February - April)
          Easter Outreaches
          Elim Bible Institute Internships
          Summer Outreaches (June - August)
          Annual 9/11 Outreaches (September)
          October Compassion Outreach Weekend
          Thanksgiving Outreach Weekend
          Christmas Compassion Weekend
          Christmas Compassion Week
          Week-Long Outreaches
          Work Teams (Skilled Construction Teams)
          Lodging ONLY
          Christian Dorm Program
          Christmas in NYC
          Jr./Sr. Trip
          City Impact
          Silver Seniors
          Other

Please indicate age range of ministry team:
          17 years and younger (every 3 members under 18 years old must be accompanied by
                                                                                                          an adult who is 21 or older)
          18 to 25 years old
          26 to 40 years old
          41years old and above