Debriefing Application form

Do you have health & accident insurance that is valid in France?YesNo
Policy Number
Company Name
Expiry Date
Are you taking any prescribed medications?YesNo
If yes, please explain
Are you under the care of a professional psychologist or psychiatrist?YesNo
If you are on a special diet or have any special food requirements, please explain

Are you bringing your children with you?YesNo
If so, give their names and ages:
Do you want them debriefed? If yes, please fill out a Child Application Form separately for each child YesNo
If not, are you bringing a nanny with you?YesNo
If yes, please give the nanny's name(s)

Family name of person in your home church responsible for your release to the mission field
First name
Responsibility/Title
Email
Telephone Include country code
Fax
Postal Address
Family name of person directly responsible for your work on the mission field
First name
Responsibility/Title
Email
Telephone Include country code
Fax
Postal Address

Country you are serving in
Length of stay on field this term
Total years/months on the field Please specify whether years or months
Reasons for coming home this time
Reasons for requesting debriefing at Le Rucher Please specify in a few lines
Preferred Language for Debriefing - 1st choice We will try to honor your 1st choice, but this will depend on availability
Preferred Language for Debriefing - 2nd choice
1st choice - dates preferred
2nd choice - dates preferred
3rd choice - dates preferred