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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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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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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