APPLICATION FOR MISSION TRIP TO TIJUANA: January 20-22, 2023 Nickname for Name Badge Home Address * City * State * Zip Code * Home Phone Cell Phone Work Phone Email * Date of Birth * Age * Passport Number * Date of Issue * Expiration Date * Place of Employment * Occupation * Do you speak other languages proficiently enough to serve as an interpreter? If yes, please specify languages you speak Church regularly attending, if any Are you willing to give a 5 to 10 minute morning devotion? If you are not a medical professional, are you interested in participating as a Helping Hand in any of the areas listed below: Type of License License Number Years of Experience Glove Size: Small Medium Large FOR ALL APPLICANTS PLEASE ANSWER THE FOLLOWING QUESTIONS Please specify your size for a Team Men’s T-shirt or Button Down: Small Medium Large X-Large XX-Large XXX-Large How did you hear about Project Compassion? Is this your first mission with Project Compassion? Yes No Please tell us about a previous mission and or cross-cultural experience you have had. What are you hoping to get out of the mission trip? Do you have specific skills you would like to use on the trip? Do you have any physical limitations? Yes No If yes, please explain: Do you have a history of medical problems requiring on going treatments? Yes No If yes, please explain: Are you currently taking any medications? Yes No If yes, please list: Do you have any allergies to food or medication? Yes No If yes, please list: Please provide your Primary Care Physicians Name and Phone Number In case of an emergency notify, Relationship Phone Number PLEASE READ THE STATEMENTS BELOW AND ATTEST TO YOUR UNDERSTANDING OF THE STATEMENT WITH YOUR SIGNATURE OR INITIALS I have read and agree with the Mission Statement, Vision Statement and Statement of Belief of Project Compassion (linked below). Please agree by selecting the checkbox. If you do not concur with the Project Compassion Agreement, please explain why. I agree to conduct myself in compliance with Project Compassion principles and team policies at all time 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 to the United States on the next available flight. Date Please initial in the box below each statement. 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. * Extra Expenses: I understand that I am responsible for costs that are not covered by the cost of my trip. * I give my permission to Project Compassion to publish photos and testimonies that are appropriate and related to the Mission Trip. LIABILITY RELEASE – RELEASE OF ALL CLAIMS Consent to Electronic Signatures and Documents By completing this consent form you are providing electronic consent to the use of electronic documents and signatures. Your electronic signature on any of the electronic documents, including this Application and All Consent Statements, will bind you to that document the same as if you had signed a paper copy of the document with an ink pen. You agree to not contest the validity or enforceability of any electronic document you receive or electronically sign because the document and your signature are in electronic form. You understand that you should contact us to report any problem with your application. You should retain a copy of all electronic documents we provide to you, including this Application and all Consent Statements, for your future reference. You can do this by printing the page on paper or saving it to your computer. The parties agree that this application may be electronically signed. The parties agree that the electronic signatures and initials appearing on the application are the same as handwritten signatures for the purposes of validity, enforceability and admissibility. By selecting the “I Accept” button, you are signing this Agreement electronically. You further agree that your signature on this document (hereafter referred to as your “E-Signature”) is as valid as if you signed the document in writing. Date * Time * 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. Date (mm/dd/yyyy) 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 * In order for your application for the Mission Trip to Tijuana to be complete, please provide ALL of the following information through the upload link below: * 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 info@ProjectCompassion.org with any questions you may have. Thank you for your interest in Project Compassion!