Your Name (required) Mission Location Applying For (required) Date of Trip(required) Full Name EXACTLY at it appears on your passport Passport Number Is your passport valid for at least 6 months on the departure date? YesNo Nickname for name badge Date of Birth Gender MaleFemale Address City/State/Zip Home Phone Cell Phone Work Phone Email Home Airport Place of Employment Occupation Work Address Do you speak other languages proficiently enough to serve as an interpreter? YesNo If YES please list which one(s) Church regulary attending, if any Address and Phone Are you willing to give a 5-10 minute morning devotional? yesno For your team shirt; please specify size: xssmlxlxxlxxxl As a non-medical person I am interested in participate as a Helping Hand by: RegistrationCrowd ControlPrayer/EvangelismTeaching Health EdTranslatingAs Needed (It is not always possible to assign everyone to where they requested) Students: College/High School Area of Study Level of Education *Medical Personnel Only* Type of License/Certificate License # Medical Professional's Sterile Glove Size SmallMediumLarge How did you hear about Project Compassion? Previous mission and/or cross-‐cultural experience? What are you hoping to get out of the missions trip? Do you have specific skills/gifts you would like to use on the trip? Please send more information on the following CEU's for RN's and LVN'sSupport Raising Information I have read the Mission Statement, Vision Statement and Statement of Belief I also concur to the principles of Project Compassion YesNo If No-please explain why 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. I understand that failure to do so may result in my return on the next available flight. YesNo I give my permission for Project Compassion to publish photos and testimonies that are appropriate and related to the Mission Trip. YesNo Medical/Liability Release (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 recreation and work activities. Yes The undersigned further consents to the administration of first aid and/or doctor’s care, or any other form of medical treatment necessitated by illness or injury that may require the same. In the event of the necessity 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 medical care on behalf of the participant. The undersigned furthermore attests and verifies that he/she is physically fit and has no medical condition(s) that would prevent him/her from performing the volunteer services for which he/she is applying. Name: Who to Notify in Case of Emergency 1. Emergency Contact Name Relationship Phone 2. Emergency Contact Name Relationship Phone Participant Insurance Company Policy Number Do you have any physical limitations? If yes; explain Do you have a history of medical problems requiring on-going treatment? If yes; explain Are currently taking any medications? If yes; list Do you have any allergies to food or medications? If yes; list Please list Primary Physician name Phone number Beneficiary Name Phone Number Relationship Please read the information below and check each box DEPOSIT. Upon approval of my application, a $300 non-refundable deposit is needed to reserve my space on the team and will be applied to the costs of my trip. Yes PREPAYMENTS. Airline tickets or other outreach expenses will not be paid for me unless my Project Compassion trip account payments are up-to-date. Yes AIRFARE.Included air travel costs are based on departures from San Diego or Los Angeles International Airport. If I am flying from another city, Project Compassion will make arrangements for me to join the team at the departure airport or the connecting airport, whichever is most feasible and economical. I will be responsible for any additional travel costs that may result with these connections. Yes LUGGAGEAirlines have varying fee structures for baggage, usually allowing two free bags per person on international flights. On Project Compassion trips each member has two bags—one personal bag and one Project Compassion bag. Should the airline allow only one free checked bag, the Project Compassion luggage is designated as the free bag. In these instances, I can choose to only use a carry-on bag to avoid being charged for a personal checked bag. Yes EXTRA EXPENSEI am responsible for costs for country entry/exit fees or visas when applicable. These additional expenses are not calculated into the cost of my trip. Should there be known costs I will be notified by Project Compassion. At times, Project Compassion does not know of added fees until arriving in the country. Yes CANCELLATIONIf, at any time, I cancel my registration on an outreach, all funds not already expended on my behalf may be used for another outreach with Project Compassion within 12 months of the cancellation. No monies are returned directly to me. Yes REFUNDSFunds submitted in excess of the minimum required contributions for each outreach will be treated as a general donation to Project Compassion and are not refunded to me. (This often covers expense shortfalls experienced on some mission trips.) Yes In order for your application to be complete, please include the following either by uploading them or mailing them into us] -$50 application fee (Making deposit online coming soon) -A recent photo -A copy of verifying Medical information with initials -A color copy of your driver's license/certificate -A copy of your professional license/certificate(if applicable) -A color copy of your passport -If under 18 years old, a copy of your birth certificate -After you receive your acceptance letter you will need to send in a $300 non-refundable deposit to be placed on the team. You will be advised if additional color passport photos are needed for visas.