dear prospective u. s. m.a.p.s. team...

Mail this form and check(s) to: U.S. Missions MAPS Office * 1445 N Boonville Ave. * Springfield, MO 65802 * Phone:1-877-346-6277

Dear Prospective U. S. M.A.P.S. Team member(s): Thank you for your interest in the possibility of participating in a construction project or evangelism outreach. The mission fields in the United States are indeed ready for harvest and workers are needed. Construction and evangelism projects exist from border to border and coast to coast. No matter where you go, there is a need that you and/or your team could help meet and minister to. I would count it an honor to have you call our office and allow us to share the needs and locations of these projects with you. Should you feel God leading you toward being part of a U. S. M.A.P.S. project, here are a few easy steps to follow.

• Fill out and return the enclosed application packet along with the application fee. (NOTE: For teams of four or less the application fee is waived.)

• Make sure the Assumption of Risk Form and Insurance List are in our office two weeks prior to

departure. In addition to the blessing of being involved in a missions project, as a registered U. S. M.A.P.S. team, your church can receive World Missions giving credit. Again, thank you for inquiring about a U. S. M.A.P.S. project. If you have any questions, please do not hesitate to give us a call. We look forward to hearing from you. Together, Building His Kingdom,

Jerry Bell Director, U. S. M.A.P.S.


U.S. Missions MAPS

Individual or Team Application Form For Prayer, Evangelism, or Construction Assignments

_________________________________________________________________________________________________

1. Name of individual volunteer(s) or team contact person. Name___________________________________________ Date________ Work (_____)____________ Home (_____)___________ Address______________________________________________________City_____________________ State____ Zip__________ 2. Name of the church represented by this assignment. Church_________________________________________ Address_____________________________________________________ City_____________________________ State____ Zip________ Church (_____)______________ Fax (_____)________________ Pastors Signature _________________________________________________ 3. This MAPS assignment application is for: Dates available________________________________________________ Individual Volunteers (Number__________) Construction Team (Number__________) Evangelism Team (Number__________) 4. Name of project with which you plan to work ___________________________________________________________________ City ____________________________________ State________________ Pastor/Missionaries Name _______________________________________ 5. Extra funds your church can give for material costs $____________ 6. Application fee: (non-refundable) $35 for teams. 7. Please check the type of work that your team plans on doing. Other languages spoken_____________________________________________________ ____ Carpentry ____ Renovation ____ Street Ministry ____ Cement Work ____ Landscape ____ Vacation Bible School ____ Drywall ____ Electrical ____ Other ______________________________ ____ HVAC ____ Plumbing


PAPERWORK THAT IS REQUIRED IN THE MAPS OFFICE

(prior to your departure) FOR YOUR CHURCH TO RECEIVE

WORLD MISSIONS GIVING CREDIT

1. Individual or Team Application Form along with application fee. 2. Assumption of Risk and Insurance Election Form signed by each team member. 3. MAPS requires each person on your team to have insurance

coverage. If a team member does not have insurance that covers them out of state, they can buy the insurance offered through the

Assemblies of God and: . Sign Beneficiary Designation form . Send in Insurance List Report along with insurance fee

(this form should have all the names on that are obtaining the insurance)

4. If you have any minor children (that qualify for taking a MAPS

trip) that are accompanying the team, the MAPS office needs the Parental Consent, Certification, and Medical Authorization form

returned. These forms can be obtained by calling the MAPS office at 1-877-346-6277.


Dear MAPS Worker: MAPS requires each person on your team to have insurance coverage. If you do not have your own policy, we offer coverage through Guarantee Trust Life (GTL) at a cost to you of $2.60 per person per day. Please complete the enclosed Insurance List Report with all names to be insured, including each day of travel, and return it with your check made payable to U.S. Missions MAPS in the envelope provided. Send the list 2 weeks prior to your departure (and write “insurance #309796 CL 08” on the memo line). A claim form will be mailed to the team contact person upon receiving the Insurance List Report, Insurance premium and Individual or Team Application Form. Please note that: * This insurance is only available if you are 100 or more miles from home

* GTL will not pay claims for pre-existing conditions * Submit one claim for each illness or accident. * Bills are to be paid before submitting claim (if possible) and mailed with receipts within 90 days for reimbursement to: Guarantee Trust Life Insurance Co. PO Box 1148 Glenview, IL 60025 * Claims not following proper procedures will be returned to you. If you have any questions concerning your insurance, please feel free to contact us. May the Lord richly bless all your endeavors for His kingdom and give you a safe and profitable trip!

--MAPS Office Staff


GUARANTEE TRUST LIFE INSURANCE COMPANY (GTL)

Summary of health Coverage

24-Hour Accidental Death &

Dismemberment

$100,000

PTD Monthly Accident Limit

88 Month Maximum

$1,000

PTD Monthly Sickness Limit 50 Month Maximum

$250

PTD Sickness Waiting Period

3 Months

Accidental Medical Limit

$50,000

Sickness Medical Limit

$10,000

Coinsurance

100%

Deductible per Occurrence

$50

Medical Evacuation Limit

$75,000

Premium

$2.60 per day, per person


1. ORGANIZATION NAME Assembly of God U.S. Missions (MAPS Construction) 2. SPECIFIC GROUP Name Address City State Zip 3. DATES OF TRIP 20___ to 20___ Total No. of Days ______________

5. DESTINATION 6. REPORT PREPARED BY NAME (please print) ________________________________ Signature ________________________________ Position ______________________________ Telephone Number (____) _____________ Date __________ Insurance is $2.60 per person/per day

NAME FEE NAME FEE 1. 21.

2. 22.

3. 23.

4. 24.

5. 25.

6. 26.

7. 27.

8. 28.

9. 29.

10. 30.

11. 31.

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20. 40.

Page No. __________ Total No. of Insured _________ Amount Enclosed

POLICY NUMBER

ACT. # IMPORTANT Premium will be calculated for everyone listed for the dates shown above (unless individual dates are indicated by the name.) Include travel dates


IMPORTANT! READ INSTRUCTIONS CAREFULLY

**This form along with the premium, must be returned to the MAPS office 2 weeks prior to your trip.

Please keep a photocopy for your records.


Guarantee Trust Life Insurance Company

Beneficiary Designation

Insured’s Name (print) ___________________________________________________ Last First Middle Initial

Start Date of Travel ______________________________________________________ Month Day Year

Beneficiary _____________________________________________________________ Beneficiary’s Relationship to Insured _______________________________________

Policyholder: ________Assemblies of God_________________________________ Policy Number: ________246-018-001 S__________________________ Signature of Insured ____________________________________________________ Date of Signing ________________________________________________________

*Note: one form required for each insured individual


ASSUMPTION OF RISK AND INSURANCE ELECTION

Mission America Placement Service MAPS Team Member

PART 1 – Assumption of Risk I, ________________________________________ (name of volunteer), in consideration of my acceptance as a short-term volunteer with the Mission America Placement Service (MAPS) of the Assemblies of God U.S. Missions of the General Council of the Assemblies of God, USA, represent and agree that: 1. I am a volunteer worker and acknowledge that I am not an employee of MAPS, the Assemblies of God U.S. Missions, or the General Council of the Assemblies of God, USA. 2. I am aware of the hazards and risks to my person and property associated with serving in a missions capacity, such hazards and risks including, but not being limited to, death or injury by accident, disease, terrorist acts, weather conditions, inadequate medical services and supplies, criminal activity, and random acts of violence. I accept my assignment with full awareness of these risks, and subject to the insurance coverage described below, I voluntarily assume all risks of death, injury, illness and damage to myself or any members of my family associated with such risks, or any damage to my personal property. I further recognize that such risks have always been associated with missionary service. (2 Corinthians 11:23-28)

3. I attest and certify that I have no medical condition that would prevent me from performing my duties. 4. Subject to insurance coverage described below, I waive any and all claims for damages which I , or my heirs or successors, may have against MAPS, the Assemblies of God U.S. Missions, the General Council of the Assemblies of God, and District Council of the Assemblies of God, the local church/individuals sponsoring the MAPS trip/assignment, or any agent, employee or member of any such organization, arising from my death, injury, or illness, or any property damage or loss occurring during the term of my assignment or as a result of my assignment. 5. In the event that I have minor children who will accompany me on my assignment, I, acting both on my own behalf and in their behalf as their parent or legal guardian, and subject to the insurance coverage described below, do hereby assume all risks of death, illness, or injury that they may suffer as a result of said assignment, from those causes described above. 6. I understand and accept the following policy of the Assemblies of God U.S. Missions regarding ransom payments:


The U.S. Missions Board has determined that it will not pay ransom nor yield to the demands of anyone who takes hostage one of our missionary family or staff hostage. The Assemblies of God U.S. Missions pledges itself to every effort in prayer and all other appropriate means to obtain the release of one taken hostage should it ever occur. This policy was made after sufficient study of the policies of other evangelical missionary societies and after considering advice of the United States State Department. 7. I expressly waive any defense to the enforcement of any provisions of this commitment arising from a claim of lack of consideration and warrant that this commitment constitutes a legal, valid, and binding obligation upon me enforceable against me in accordance with its terms. 8 I expressly agree that this assumption of risk and indemnity agreement is intended to be as broad and inclusive as permitted by law. I FURTHER STATE THAT I HAVE CAREFULLY READ THE FOREGOING ASSUMPTION OF RISK AND UNDERSTAND ITS CONTENTS, AND I VOLUNTARILY SIGN THIS RELEASE AS MY OWN FREE ACT. PART 2 – Insurance Election I am aware of the hazards and risks to my person associated with serving in a missions capacity, as described above. I further understand that MAPS currently offers the insurance coverages summarized below, that I am responsible for the cost of such insurance, that these coverages are subject to change, and that I am responsible for obtaining any additional insurance coverage that I consider necessary: * $100,000 24-hour accidental death and dismemberment

* $ 1,000 Monthly limit for permanent total disability based on an accident (88-month maximum, with a 12- month waiting period). A lump sum payment of $12,000.

* $250 Monthly limit for permanent total disability based on illness (50 month maximum, with a 3-month waiting period).

* $50,000 Accident medical limit. * $10,000 Sickness medical limit. * $50 Deductible per occurrence. * $75,000 Medical air taxi limit

Please check the appropriate statement: ______I have adequate insurance coverage and do not desire the insurance coverage described above. ______I desire the above-described insurance coverage with Guarantee Trust Life Insurance Company SIGNATURES


Date: _____________________________ ____________________________________________________________________________ Legible Signature Legible Signature of Spouse (if he/she will accompany you on this trip)

Address City State Zip IMPORTANT: Please have two (2) witnesses observe your signing of this form, and have the witnesses sign below. They must be at least 18 years old, and they cannot be your relatives. _______________________________________________________________________ Witness’ legible signature Address _______________________________________________________________________ Witness’ legible signature Address Team Trip Information: Name of Church:_______________________________________ City, State: _______ Destination: _______________________________________________________________________ Date of Departure: ______________________Date of Return: ____________________

Please send the signed Assumption of Risk form to this address prior to your trip:

U.S. Missions MAPS

1445 N Boonville Ave. Springfield, MO 65802


Code of Conduct

Please place your initials by each statement below:

As a MAPS team member I realize the important role I play as an example to those in the United States and abroad. I understand that I represent not only my local church, but also the MAPS Department, the Assemblies of God U.S. Missions, the General Council of the Assemblies of God, and the United States as a whole. I understand the Assemblies of God official statement of abstinence from alcohol, tobacco, and controlled substance use and/or abuse. In respect to God, the Assemblies of God, its missionaries, pastors, and the national church that I will be ministering to, I will refrain from: _______ The purchase and/or use of any kind of alcoholic beverage _______ The purchase and/or use of any tobacco products _______ The purchase and/or use of any other controlled substance (Does not include the use of personal medications, as prescribed by a doctor, or the use of necessary over-the-counter medications such as Aspirin, Tylenol, Pepto-Bismol, etc.) I __________________________________, have read and understood the above policy.

I promise to forego my personal convictions on the subject in order to maintain unity and

to avoid controversy in the body of Christ.


Signed: _____________________________________ Date: ____________ Address: ______________________________________________________ City: ____________________ State: ___________ Zip Code: ___________


PARENTAL CONSENT, CERTIFICATION, AND MEDICAL AUTHORIZATION

Parents and legal guardians of minor children are required to complete this form and return it to the MAPS office. The information requested is designed to assist MAPS in providing for the safety of minors during MAPS trips. This form is not valid if completed by the child traveling. This form must be completed by a parent or legal guardian of the child listed below. General Information (please print)

Child’s Name____________________________________ Date of Birth________________ Father’s Name _________________________Mother Name__________________________ Child’s Address_____________________________________City_______________ST____ Home Phone No.______________________Parents Work Phone No.___________________ Family Doctor _____________________________ Dr. Phone No. _____________________

Insurance Company Covering Child Insurance Company Covering Child ______________________________________________ Policy No. __________________________________________________________________ _____ Check here if additional coverage is desired.


Consent, Certification, and Assumption of Risk I, the undersigned, being the parent or legal guardian of the child named above (the “child”), do hereby consent to the child’s participation on a MAPS assignment sponsored by the MAPS Department of the Assemblies of God to (name of project assignment) _____________________, including, but not limited to, all the activities customarily associated with a MAPS trip. I am aware of the hazards and risks associated with such a trip including, but not limited to, death or injury by accident, disease, terrorist acts, weather conditions, inadequate medical services and supplies, criminal activity, and random acts of violence. Further, I certify that the child is physically fit and adequately trained to participate in such a MAPS trip. I understand that while the above-named child participates on a MAPS trip, he or she is responsible to comply with all orders and directives of the MAPS team leader and/or the Assembly of God missionary in charge of the project. I am aware of the hazards and risks to my child and his or her property associated with serving in a missions capacity, such hazards and risks including, but not being limited to, death or injury by accident, disease, war, terrorists acts, weather conditions, inadequate medical services and supplies, criminal activity, and random acts of violence. I accept my child’s assignment with full awareness of these risks, and, subject to the insurance coverages described below, I voluntarily assume all risks of death, injury, illness, and damage to my child associated with such risks, and any damage to his or her personal property. I further recognize that such risks have always been associated with missionary service (2 Corinthians 11:23-28). Subject to insurance coverages described below, I waive and release any and all claims for damages which I, or my heirs or successors, may have against MAPS, the U.S. Missions of the Assemblies of God, the General Council of the Assemblies of God, any District Council of the Assemblies of God, the local church sponsoring the MAPS trip, or any agent or employee of any such organizations, arising from my child’s death, injury, or illness, or any property damage or loss occurring during the term of his or her assignment or as a result of his or her assignment. Subject to the insurance coverage described below, I do hereby assume all risks of death, illness or injury that my child may suffer as a result of said assignment, from those causes described above. I understand and accept the following policy of the Assemblies of God U.S. Missions regarding ransom payments:

The U.S. Missions Board has determined that it will not pay ransom nor yield to the demands of anyone who takes hostage one of our missionary family or staff hostage. The Assemblies of God U.S. Missions pledges itself to every effort in prayer and all other appropriate means to obtain the release of one taken hostage should it ever occur. This policy was made after sufficient study of the policies of other evangelical missionary societies and after considering the advice of the United States State Department.

I expressly waive any defense to the enforcement of any provisions of this commitment arising from a claim of lack of consideration and warrant that this commitment constitutes a legal, valid, and binding obligation upon me enforceable against me in accordance with its terms. Medical Questionnaire 1. Is your child presently being treated for an injury or sickness or taking any form of medication for

any reason? Yes ______ No ______ If yes, please explain: ______________________________


________________________________________________________________________ 2. Is your child allergic to any type of medication? Yes ______ No ______ If yes please explain:_______________________________ _______________________________________________________________________ 3. Does your child require a special diet? Yes ______ No ______ If yes, please explain: ______________________________ _______________________________________________________________________ 4. Does your child have any allergies other than medical? Yes ______ No ______ If yes, please explain: ______________________________ ______________________________________________________________________ 5. Does your child ever sleep walk? Yes ______ No ______ 6. Can your child swim? Yes ______ No ______ 7. Does your child have any physical condition or illness that would prevent him/her from

participating in rigorous activity? Yes ______ No ______ If yes, explain below. A written release must be submitted by your physician authorizing your

child to participate in this activity/trip. _______________________________________________________________________ _______________________________________________________________________ Insurance Election I am aware of the hazards and risks to the child associated with serving in a missions capacity, as described earlier. I further understand that the following insurance coverage with Guarantee Trust Life is optional, that this coverage is subject to change, and that I am responsible for obtaining (at my expense) this and or any additional insurance coverage that I consider necessary for the child: *$100,000 24-hour accidental death and dismemberment *$ 1,000 Monthly limit for permanent total disability based on an accident (88-month maximum with a 12-month waiting period) *$ 250 Monthly limit for permanent total disability based on illness (50 month maximum with a 3-month waiting period) *$ 50,000 Accident medical limit *$ 10,000 Sickness medical limit *$ 50 Deductible per occurrence *$75,000 Medical evacuation limit Please check the appropriate box: _____ I desire to purchase the above-described insurance coverage for the above mentioned

child. _____ I have adequate insurance coverage that is at least the coverage listed above and do not desire

additional coverage for the above-mentioned child.


Medical Treatment Authorization I understand that I will be notified in the case of a medical emergency involving my child. However, in the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill. I authorize the director or properly appointed staff to make emergency medical care decisions on behalf of my child, if required by law or a health care provider. I agree to notify the MAPS office in the event of any health changes that would restrict my child’s participation on a MAPS trip. I also understand that the adult supervisors reserve the right to restrict my child from any activity that they do not feel is within the physical capabilities of my child. I expressly agree that this assumption of risk and indemnity agreement is intended to be as broad and inclusive as permitted by law. I further stat that I HAVE CAREFULLY READ THE FOREGOING ASSUMPTION OF RISK AND UNDERSTAND ITS CONTENTS, AND I VOLUNTARILY SIGN THIS RELEASE FOR MY CHILD AS MY OWN FREE ACT. ______________________________________________________ ____________________ (Signature of Parent/Guardian) (Date) ______________________________________________________ ____________________ (Signature of Parent/Guardian) (Date)

STATE OF ____________________________ COUNTY OF __________________________ On this ______________day of ___________________, 20______, Before me, __________________________, a Notary Public in and for said state personally appeared ___________________, known to me to be the person who executed the within agreement and acknowledged to me that he/she executed the same for the purpose therein stated. Signature: ____________________________ My Commission expires: _________________________


EXPENSE REPORT Expense report should be completed as soon as the team returns from their trip. Forms should be as complete and accurate as possible in order for appropriate credit to be given. If more than one church is involved, complete a separate form for each church. Form may be duplicated. To receive credit for the current year, the completed report must be received by U.S. Missions no later than December 15.

Team Coordinator _____________________________________________________________ Address ______________________________________________________________ Phone # _______________________Number of Team Members ___________ Dates of Trip _______________________ Trip to ____________________

City State Project Name _________________________________________________________________ Host Missionary/Pastor _________________________________________________________ Give World Ministries Credit to: Church ________________________________________________________________ Address _______________________________________________________________


Please turn over to complete. Meals $_______________________ Hotel $_______________________ Airfare, Bus, Taxi $_______________________ Car Rental, Airport Parking $_______________________ Telephone $_______________________ Insurance $_______________________ Auto Mileage @ 51¢ per mile $_______________________ Other (give explanation) _____________________________ $_______________________ _____________________________ $_______________________ _____________________________ $_______________________ _____________________________ $_______________________ Sub Total $_______________________ Funds and/or Building Materials left with Missionary/Pastor $_______________________ (Attach itemized list and receipts for funds) Total Credit Requested $_______________________ Signature ______________________________________ Person Completing Form

MAIL FORM TO:

U.S. MAPS 1445 N Boonville Ave. Springfield, MO 65802

Telephone: 1-877-346-6277

FAX: 417-862-0409

World Ministries Giving Credit will not be issued for any one of the following reasons: 1. Failure to send in Individual or Team Application Form along with application fee. 2. Failure to send in Insurance List Report (if taking the insurance offered) 3. Failure for all team members to complete and return the following form: . Assumption of Risk and Insurance Election Form . Guarantee Trust Life Beneficiary Form (if taking the insurance offered) 4. Failure to submit an expense report form by December 15.

dear prospective u. s. m.a.p.s. team...

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