mission Request

Accompanied with Minor?

If answered "yes" please call 470-709-6575 before completing this application

Mission Request

Long Term Program

Short Term Program

Other

Reason for "Other"

If answered "other" please call 470-709-6575 before completing this application

Is The Survivor Currently In a Program?

How Long Has The Survivor Been Out Of Their Trafficking Situation?

Is The Survivor Going To a Program?

Any Know Safety Concerns?

Type N/A if none

Does The Survivor Require An Advocate During Travel?

Referring Organization

Referring Contact Name

Full Name

Referring Contact Phone

Referring Contact Email

Who Is Dropping the Survivor Off?

Full Name & Number

Is Law Enforcement Involved

Yes

How Long Has The Survivor Been In Your Program?

Has The Receiving Organization Confirmed Acceptance?

Receiving Organization

Receiving Point of Contact:

Receiving Phone

Receiving Email

Who Is Picking Up the Survivor?

Very important: his person must be the person picking up the survivor. We will not allow the survivor to be placed in a rideahshare, taxi or anyone not listed as the pick up point of contact

Is Law Enforcement Involved

Yes

First name

Last name

Age

Weight

Does the Survivor Have Govt ID?

Favorites Things

Please list favorite snack, drink, movie or book so we can make this mission a special memory

Does the Survivor Have a Bible?

We will provide a Bible free of charge if needed

Traveling From

Nearest city or address of landmark

Traveling To

Nearest city or address of landmark

Preferred Travel Date Range

Baggage Weight

No hard shell or large cases. They will not fit. Maximum of 50lbs.

Any Survivor Concerns?

Medical, prescription Medications, recreational drug use, anxiety, PTSD, mobility limitations, pregnancy, etc

History of Substance Abuse?

Current or Sober? If Sober, How Long?

Known Allergies?

Type N/A if none

Any Medications That Must Be Readily Accessible During Travel?

Type N/A if none

How Can We Pray?