I am submitting my application for the following upcoming missions trips: *

Zimbabwe 2026 (Jul 5-13) $2800

Zimbabwe 2026 w/Adventure Days (Jul 5-16) $3500

Cambodia 2026 (Sep 1-10) $3200

Zimbabwe 2026 (Oct 19-28) $2800

Zimbabwe 2026 w/Adventure Days (Oct 19-30) $3500

Have you ever submitted a CCI application through this portal before? *

Yes

PERSONAL INFORMATION

Name *

Mobile Phone *

Email *

Address *

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Social Media Handle

Birthdate *

Gender *

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gender.female

Marital Status *

Do you have a passport? *

Yes

Submitted

CHURCH INVOLVEMENT

Do you attend church? *

Yes

What ministries/organizations outside of your local church are you involved in? *

BACKGROUND HISTORY

Have you ever been charged, arrested or convicted of a felony or misdemeanor? *

Yes

Has anyone ever brought or threatened to bring civil or criminal claim against your alleging physical or sexual abuse or sexual harrassment? *

Yes

Have you ever been reprimanded as a student or employee for harassment of another individual or other inappropriate behavior with another individual? *

Yes

PREVIOUS OVERSEAS EXPERIENCE

Please list countries, dates and nature of travel/mission organizations if applicable:

What foreign languages do you speak or read?

MEDICAL HISTORY

Please check all that apply to you:

Are you taking any medication(s) for any of the conditions specified above? *

Yes

Allergies (if none, write "none"): *

Dietary Restrictions (if none, write "none"): *

SKILLS

Select all skills that you are proficient in:

Other Skills or Details:

Hobbies:

CHARACTER REFERENCES

Reference #1 Name: *

Reference #1 Relationship: *

Reference #1 Email: *

Reference #1 Phone: *

Reference #2 Name: *

Reference #2 Relationship: *

Reference #2 Email: *

Reference #2 Phone: *

TESTIMONY

Please check al the statements that apply to you. *

I believe that Jesus was born of a virgin, died on a cross and rose from the dead.

I believe that the Holy Bible is accurate and without fault.

I believe that surrendering to Jesus is the only way to Heaven.

I'm not sure what I believe about Jesus.

I don't believe any of these statements are true.

Describe your personal relationship with Jesus Christ: *

Why would you like to participate in this trip? *

What would make this missions trip a success for you? *

What do you think may be the biggest challenge for you to overcome for this trip? *

Describe your strengths: *

Describe your weaknesses: *

Please provide an overview of your testimony (your upbringing, life before Christ, how you became a Christian, etc): *

AGREEMENT

Which of the following statements is true? *

I am over the age of 18.

I am under the age of 18 but my parent or guardian is submitting an application to go on this missions trip with me.

I am under the age of 18 but my parent or guardian is willing to sign notarized permissions for me to travel alone if my application is approved.

Please select the box if you understand and agree to the statements: *

I understand that if my application is approved, I will be responsible for raising the funds required to cover my own expenses according to the payment deadlines.

I understand that if I am unable to participate, donations are non-refundable as required for IRS compliance. While every reasonable effort may be made to apply contributed funds in a manner consistent with the donor’s intended purpose, all funds must remain under the control of CounterCulture International and may be reallocated as necessary.

I understand that if my application is approved, I will be required to obtain and upload the necessary documents and forms by the specified deadlines in order to participate.

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