1. Haiti Needs You
Haiti Alternative Spring Break March 29, 2012 through April 6, 2012
Team Member Information
1. FULL NAME: (as on passport) ________________________________________________
2. MALE___ FEMALE___ 3. PLACE OF BIRTH ____________ 4. BIRTHDATE __________
5. AGE _______ 6. T-Shirt Size? Adult S M L XL XXL
7. CURRENT ADDRESS _______________________________________________
CITY _____________________ STATE _____ ZIP __________
8. PHONE ____________________ E-MAILADDRESS: ________________________________
IF UNDER THE AGE OF 18, PLEASE GIVE THE FOLLOWING INFORMATION:
9. FATHER’S NAME (first, last) __________________________________________________
10. MOTHER’S NAME (first, last, maiden) ___________________________________________
OR NAME OF LEGAL GUARDIAN (first, last)___________________________________
11. MEDICAL HISTORY: DO YOU HAVE ANY MEDICAL PROBLEMS? ___YES ___ NO
EXPLAIN______________________________________________________________
CURRENTLY ON MEDICATIONS? ______________________________________________
12. SCHOOL ATTENDING:
____________________________________________________________
13. HAVE YOU EVER TRAVELED INTERNATIONALLY? _____ WHERE? __________________
14. PASSPORT NUMBER ______________________________________
PASSPORT EXPIRATION DATE _____________________________
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2. Haiti Needs You
Medical Release Form
Participants Name: _______________________________________________
Insurance Company: _______________________________________________
Policy Number: ___________________________________________________
Family Physician: _________________________________________________
Address: ________________________________________________________
Telephone Number(s): _____________________________________________
Known Allergies: __________________________________________________
Any known medical conditions: ______________________________________
________________________________________________________________
________________________________________________________________
Person(s) to notify:
First Choice Name and relationship: ___________________________________
First Choice Phone #: _____________________
First Choice Cell Phone #: __________________
Second Choice Name and relationship: ________________________________
Second Choice Phone: ____________________
Second Choice Cell Phone #: _______________
CONSENT FOR MEDICAL TREATMENT:
This consent is for ____________________________________________
(Print participants name)
I hereby give my permission for any and all medical attention necessary to be
administered in the event of an accident, injury, sickness, etc under the direction of
the person(s) listed above. I also assume all responsibility for cost of treatment. If
the above named participant needs emergency medical treatment and the
parent(s), family doctor, or emergency contact person can not be reached, consent
is hereby granted for such emergency treatment as may be considered necessary
in the opinion of the attending physician.
Signed __________________________________________ Date ___________
Parent/Guardian signature _________________________ Date ____________
(Must sign if your child participant is under 18 years of age)
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3. Haiti Needs You
Alternative Spring Break Mission Trip 2012
March 29, 2012 through April 6, 2012
MY COMMITMENT
(Read before signing…)
As an ambassador of Christ, my country, and school, I will adhere to the guidelines
established by the local authorities in Haiti, my school, Haiti Needs You, and the team
leader. I understand that I am subject to disqualification from the team for failure to follow
these guidelines. I also understand that if I break any rules while in Haiti that I may be
sent home early at my own expense.
I realize Haiti Needs You is not responsible for sickness, accident, death, terrorist acts,
loss of personal possessions, or any expenses incurred beyond normal involvement. On
behalf of myself and my heirs, (and participant, if participant is under 18), I personally
assume all such risks, whether foreseen or unforeseen.
I understand that the trip expenses are estimates and that costs could change due to
unforeseeable circumstances during the course of the Haiti outreach. In case of change in
cost, the participant and legal guardian of a minor assume responsibility for extra costs.
Deposits are non refundable.
The information on my application is accurate and true. I hereby give Haiti Needs You and
my school the right to use my photographs, voice and/or testimony in any type of
promotional or advertising materials. My signature affixed below (and signature of a parent
or legal guardian if I am under the age of 18 years) signifies my approval and commitment
to all listed above.
Signed __________________________________________ Date _________________
Parent/Guardian signature _________________________ Date __________________
(Must sign if your child is under 18 years of age)
Complete, sign and return all forms with $200 deposit.
Make checks payable to Haiti Needs You
Haiti Needs You
1011 Arianna NW
Grand Rapids, MI 49504
More information can be found at www.haitineedsyou.com or www.haitimission.yolasite.com
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