Full Name (required) Nickname for Name Badge Home Address (required) City (required) State (required) Zip Code (required) Country (required) Home Phone (required) Cell Phone (required) Work Phone Your Email (required) Date of Birth (required) Age (required) Gender (required) FemaleMale Passport Number (required) Passport Date of Issue (required) Passport Expiration Date (required) Employer (required) Occupation (required) Do you speak other languages proficiently enough to serve as an interpreter? (required) YesNo If yes, please specify the languages you speak. Church regularly attending, if any: If you are not a medical professional, are you interested in participating as a Helping Hand in any of the areas listed below: RegistrationPrayerTranslatingCrowd ControlHealth EducationAs Needed For Medical Personnel Type of License License Number Years of Experience Glove Size SmallMediumLarge Please Read and Sign I agree to conduct myself in compliance with Project Compassion principles and team policies at all times while among the team members, with the hosts and with those whom we serve. (required) Signature (please use your mouse to sign below) (required) Date (required) I give my permission to Project Compassion to publish photos and testimonies that are appropriate and related to the Mission Trip. Signature (please use your mouse to sign below) (required) Date (required) Medical and Liability Release Form – Release of All Claims In consideration for being accepted by Project Compassion, Inc. for participation in an event, I do hereby release, forever discharge and agree to hold harmless Project Compassion and the Directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses of any nature whatsoever which may be incurred by the undersigned and the participant that occur while said person is participating in the above described trip or activity including work activities and recreation. (required) Signed this (required) Day of (required) Year (required) The undersigned further consents to the administration of first aid and or doctors care, or any other form of medical treatment necessitated by illness or injury that may require the same. In the event of the neccessity of such care or treatment as heretofore described, the undersigned agrees to hold harmless and indemnify said organization, its directors, employees and agents from any acts of malfeasance and or failure to act on the part of those chosen to administer care on behalf of the participant. The undersigned furthermore attests and verifies that he or she is physically fit and has no medical condition(s) that would prevent him or her from performing the volunteer services for which he or she is applying. Participant Name (required) Signature (please use your mouse to sign below) (required) In case of an emergency notify, Full Name (required) Relationship (required) Phone (required) Participants Insurance Company (required) Policy # (required) Do you have any physical limitations? (required) YesNo If yes, please explain Do you have a history of medical problems requiring on going treatments? (required) YesNo If yes, please explain Are you currently taking any medications? (required) YesNo If yes, please explain Please provide your Primay Care Physicians Name and Phone Number (required) Please read the statement below and attest to your understanding of the statement with your initials. Cancellation – if at any time I cancel my registration for a Mission Trip, all funds not already expended on my behalf may be used for another Mission Trip with Project Compassion within 12 months of cancellation. If I do not go on a Mission Trip within 12 months, the funds paid by me will be considered a general donation to Project Compassion. I understand that I will not receive a refund. Please initial Extra Expenses – I understand that I am responsible for costs that are not covered by the cost of my trip. Please initial In order for your application to be complete, please provide the following information: (required) ApplicationMedical and Liability Release FormA copy of your professional license if applicableA color copy of your passportIf under 18 years of age, a copy of your birth certificate Your application and supporting documents will be reviewed. Upon completion of the review, you will be notified if you have been accepted to participate with our Team for this Mission Trip. Please feel free to email us at firstname.lastname@example.org or please call us at (858) 485-9694 with any questions you may have. Thank you for your interest in Project Compassion!