Online Missions Application (Returnees ONLY)

Please fill in the form below ONLY if you have already been on a missions trip with the Buffalo Dream Center or Love Honduras within the last 2 years. After you submit it, you will be redirected to other forms to complete as well as the application payment.

Name & date of the trip(s) you want to participate in. *

Applicant Name *

First

Last

Address *

Apartment

City *

State/Province *

Zip/Postal Code *

Country *

Home Phone

Cell Phone *

Email *

Sex: *

• Male
• Female

Married *

• Yes
• No

Date of Birth *

Country of Citizenship *

Are you a current passport holder? *

• Yes
• No

If Yes, Passport Expiration Date

Do you presently use tobacco? *

• Yes
• No

Do you presently use alcohol? *

• Yes
• No

Have you ever used illegal or habit-forming drugs? *

• Yes
• No

If Yes, date you last used illegal or habit-forming drugs:

Do you have a criminal record? *

• Yes
• No

If yes, please explain and include all charges and sentences.

The Buffalo Dream Center reserves the right to run a criminal background check on every perspective volunteer.

Emergency Contact Name *

First

Last

Emergency Contact Address *

Apartment

City *

State/Province *

Zip/Postal Code *

Emergency Contact Phone *

Alternate Phone

Emergency Contact Email *

Emergency Contact Sex *

• Male
• Female

Relationship to Applicant *

Your general health *

• Excellent
• Good
• Fair
• Poor

Do you have any physical disability? *

• Yes
• No

If yes, please explain.

Have you ever been treated for any mental or emotional condition? *

• Yes
• No

If yes, please explain.

Please list all existing medical conditions including allergies. If none, write none. *

If you have allergies, are they life threatening?

• Yes
• No

If yes, please explain.

Please list all medication you are currently taking. If none, write none. *

Will any problems result in hard physical labor? *

• Yes
• No

Are you unusually sensitive to heat? *

• Yes
• No

Have you ever been completely or partially overcome by heat? *

• Yes
• No

If any of the above questions were answered yes, please explain:

Name of Medical Doctor *

Doctor Phone *

Insurance Carrier *

Insurance ID # *

Name of insurance carrier *

Submit