Mission Trip Participant Application Form

Mission Trip Participant Application Form
(Please submit to trip leaders)
Short Term Mission Trip Location:
Short Term Mission Trip Date:
Personal Information
Legal Name:
Address:
Last ( Legal name as appears on passport) First Middle
Street Address Apartment/Unit #
City State ZIP Code
Home Phone: ( ) Cell Phone: ( )
E-mail Address:
Birth Date: Gender: Marital Status:
Spouse’s Name:
Passport #:
Date of Expiration:
If traveling internationally, please attach photocopy of your passport page with photo and passport ID# to the application.
Occupation:
Employer: Work Phone: ( )
If Student:
School Name
Grade
Emergency Contact Information
Full Name:
Address:
Street Address Apartment/Unit #
City State ZIP Code
Primary Phone: ( ) Email address:
Relationship:
Insurance
Company:
Medical Insurance Information
Phone:
Address:
Street Address
City State ZIP Code
Group/Policy # Plan ID #
Please attach a copy of both sides of your insurance card
HPPC church insurance is only secondary. Please research your medical insurance policy and your personal coverage.
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Medical and Health History
Please describe your health, including any physical or dietary limitations
List any allergies (food, medicine, environment, insects, etc)
List any sleeping conditions you have (snoring, insomnia, etc.):
Are you able to walk at least two miles and able to carry your own bags? Yes? No?
If no, please explain
Date & provider of last tetanus shot?
Name of Primary Care Physician
Telephone:
Current Medications (both prescription and over the counter medications):
(use separate sheet, if necessary)
Name of Medication Dosage (strength, frequency) Reasons for taking medication
Check All That Apply:
Diabetes Heart trouble Fainting
Asthma Epilepsy Emotional issues
Physical disability High Blood Pressure Bee/wasp reactions
If you answered yes to any above conditions please explain:
List any medical, first Aid or CPR Training & Dates:
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Ministry Information
Do you attend HPPC Worship Services?: Yes? No? How Long?
Are you a member of HPPC? Yes? No? How Long?
If no, please list home church
References: (Church Staff, Small Group Leader):
Name:
Contact info:
Name:
Contact info:
Relationship/Position:
Have you served in a ministry at HPPC? Yes? No? If yes, which ministries and for how long?
Ministries?
How Long?
Have you had previous experience on the mission field? Yes? No? If yes, please list trips?
What talents or skills do you have that the Lord can use on this trip?
(include foreign language, music, teaching, arts and crafts, drama, etc.)
Why do you want to go on this trip?
Give a brief summary of your relationship with Jesus Christ. Include (1) When and (2) How you accepted Christ, and
(3) what Jesus means to you in your daily life.
I acknowledge and will adhere to the following policies of HPPC trips listed below:
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You must submit this completed application AND a non-refundable $300 deposit before your
application will be processed and reviewed.
In the event your application is not accepted, your check will be returned to you. Once you are a part
of the team, the check will be deposited and become non-refundable.
No one will be considered or accepted as a team member until a completed application is received.
HPPC reserves the right to deny acceptance to any person for any reason.
By submitting this application to be a part of a HPPC short-term team, you acknowledge that you are
personally responsible to pay for, or arrange funding for your portion of the trip costs.
Your Team Leader will provide information on raising financial support; however, if full support is not
raised, the balance is your responsibility. You may not begin to raise funds until you are notified of
acceptance to the team.
Your team leader will provide information regarding passports and vaccination recommendations for
the Department of Health, however it is your personal responsibility to obtain all documentation and
medical services needed for the trip. Passport and vaccination costs are not included in the trip cost
and are the responsibility of the team member.
Upon request, you agree to obtain a letter from a physician or other licensed professional who is
providing care to you stating that you do not have a medical condition or are on medications that
would put you at an increased risk and that you will be able to participate without any special
assistance.
Short-term mission trips can be rewarding and life changing; however, they can also be stressful.
Please consider factors in your personal life at this time that may distract and prohibit you from fully
committing to the mission of the trip and adapting to unusual conditions.
Once accepted, team members are expected to attend all team training meetings.
If you are unable to participate in your trip, the Team Leader must receive cancellation notice as soon
as possible. You will be responsible for all trip costs incurred up to that date.
Team members assume responsibility for their personal belongings on the trip. HPPC will not
reimburse team members for personal item that or lost, stolen or confiscated during the trip.
Applicant’s signature
Date
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Please review and sign the attached HPPC waiver, release and Indemnity agreement.
This waiver must be signed and submitted with application.
HPPC WAIVER, RELEASE AND INDEMNITY AGREEMENT
(Adult Participant)
PARTICIPANT NAME:
DATE:_________________
The undersigned (“Participant”), desiring to visit foreign countries with Highland Park Presbyterian Church (“HPPC”), and participate
in one or more campaigns, training programs or other ministry projects at various sites organized by HPPC (collectively, the
“Campaigns”), enters into this Waiver, Release and Indemnity Agreement (this “Campaign Release Form”) to induce HPPC to allow
the Participant to participate in Campaigns. The Participant understands that HPPC will rely upon this Campaign Release Form in
agreeing to allow Participant to participate in any such Campaigns. Participant acknowledges that the participation in such
Campaigns will benefit Participant and that as such Participant has received valuable consideration for the execution of this
Campaign Release Form. Based on the foregoing, Participant hereby agrees with HPPC as follows:
1. Participant does hereby release and forever discharge HPPC, and its employees, officers, agents, directors and
representatives (“HPPC Related Parties”) from any and all claims, demands, actions and causes of action for any and all injuries,
losses, liabilities and/or damages sustained, incurred or suffered by Participant during, as a result of, or in any way related to, the
Campaigns, including, without limitation, those relating to my leaving the United States of America and visiting foreign
countries, including my stay in any foreign country and my trip to and from any foreign country. WITHOUT LIMITATION
OF THE FOREGOING, THE UNDERSIGNED HEREBY SPECIFICALLY RELEASES AND FOREVER
DISCHARGES HPPC, AND ALL HPPC RELATED PARTIES FROM ANY AND ALL CLAIMS, DEMANDS,
ACTIONS AND CAUSES OF ACTION FOR ANY AND ALL INJURIES, LOSSES, LIABILITIES AND/OR DAMAGES
SUSTAINED, INCURRED OR SUFFERED BY THE PARTICIPANT ARISING DIRECTLY OR INDIRECTLY FROM
OR AS A RESULT OF THE NEGLIGENCE (BUT NOT GROSS NEGLIGENCE OR WILLFUL MISCONDUCT) OF
HPPC OR ANY HPPC RELATED PARTIES.
2. Without limiting the release set forth above, Participant acknowledges that he/she understands that HPPC makes
arrangements with airlines, hotels, travel agencies and other independent parties to provide Participant with certain services
connected with the Campaigns. These parties are not agents of HPPC, but are independent suppliers over whom HPPC has no
control, and Participant consents to all such arrangements. HPPC is not responsible for any claims, losses, damages, costs or
expenses sustained, incurred or suffered by Participant as a result of, arising from, or in any way related to any accident, injury or
death, damage, loss or delay of baggage or other property, or delay, inconvenience, loss of enjoyment, upset, disappointment,
distress or frustration, whether physical or mental, resulting from or in any way related to (1) the act or omission of any such
airline, hotel, travel agency or other independent party; (2) mechanical breakdown, government actions, weather or other factors
beyond HPPC’s control; (3) failure of Participant to obtain or receive documents, passports, visas or health certificates valid
through the date of re-entry to the United States, when required, in which case HPPC may assess a cancellation charge; (4) failure
of Participant to follow instructions, including, but not limited to, those regarding check-in and check-out times and baggage
handling; (5) cancellation or change for any reason in the travel services offered; and (6) medical or health problems or physical
disabilities, and any medical treatment or hospitalization, or lack thereof, related thereto. Participant understands HPPC reserves
the right to cancel or alter the Campaigns at any time at its sole discretion. WITHOUT LIMITATION OF THE
FOREGOING, THE UNDERSIGNED HEREBY SPECIFICALLY RELEASES AND FOREVER DISCHARGES HPPC
AND ALL HPPC RELATED PARTIES FROM ANY AND ALL LIABILITIES, DAMAGES, OBLIGATIONS, CLAIMS,
ACTIONS, CAUSES OF ACTION, LOSSES, COSTS, OR EXPENSES INCURRED OR SUFFERED BY THE
PARTICIPANT ARISING DIRECTLY OR INDIRECTLY FROM OR AS A RESULT OF THE NEGLIGENCE OF
ANY SUCH AIRLINES, HOTELS, TRAVEL AGENCIES OR OTHER INDEPENDENT PARTIES WITH WHICH
HPPC MAKES TRAVEL ARRANGEMENTS.
3. Participant gives HPPC and its representative(s) (including, without limitation, the leader of any such Campaign)
authority to request and authorize medical and/or hospital treatment for Participant in the event of any injury or sickness
sustained by Participant while on any Campaign, including, without limitation, while traveling to and from any foreign country,
and, if the need arises, to administer medical treatment, life-saving techniques or other first aid pursuant to the standard medical
kit carried on the Campaigns. Participant agrees to pay for all such treatment and to reimburse HPPC for all costs and expenses
incurred by Participant with respect to such treatment. WITHOUT LIMITATION OF THE FOREGOING, THE
UNDERSIGNED HEREBY SPECIFICALLY RELEASES HPPC, AND ALL HPPC RELATED PARTIES, FROM ANY
DUTY OR AND ALL HPPC PARTIES, FROM ANY DUTY OR OBLIGATION TO PROVIDE MEDICAL SERVICE
OR TREATMENT, LIFE-SAVING TECHNIQUES, FIRST AID, OR HOSPITAL TREATMENT FOR PARTICIPANT
IN THE EVENT OF ANY INJURY OR SICKNESS SUSTAINED BY PARTICIPANT WHILE ON ANY CAMPAIGN,
INCLUDING, WITHOUT LIMITATION, WHILE TRAVELING TO, IN, AND FROM ANY FOREIGN COUNTRY.
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4. Participant agrees and believes that the Bible commands Christians to make every effort to live at peace and to resolve
disputes with each other in private or within the Christian church (see Matthew 18:15-20; 1 Corinthians 6:1-8). Therefore,
Participant agrees and consents that any claim or dispute arising from or related to this Campaign Release Form or any Campaign
in which Participant participates shall be settled by biblically based mediation and, if necessary, legally binding arbitration in
accordance with the Rules of Procedure for Christian Conciliation of the Institute for Christian Conciliation, or if non-existent, in
accordance with the rules of the American Arbitration Association then in effect. All such mediation and arbitration shall take
place in Dallas, Texas. Judgment upon an arbitration award may be in any court otherwise having jurisdiction. Participant
understands that these methods shall be the sole remedy for any controversy or claim arising out of this Campaign Release Form
or any Campaign and Participant expressly waives any right Participant may have to file a lawsuit in any civil court for any such
claim or dispute, except to enforce an arbitration decision.
5. The invalidity or unenforceability of any particular provision of this Campaign Release Form shall not affect any other
provision hereof, and in the event that any provision hereof is found by a court of competent jurisdiction to be invalid or
unenforceable, this Campaign Release Form shall be construed in all respects as if such invalid or unenforceable provision had
never comprised a part hereof and the remaining provisions hereof shall remain in full force and effect and shall not be affected
by the invalid or unenforceable provision or by its severance herefrom. Furthermore, in lieu of such invalid or unenforceable
provision, there shall be added automatically hereto and as a part hereof a provision as similar in terms and intent to such invalid
or unenforceable provision as may be possible and be legal, valid and enforceable.
6. This Campaign Release Form may be relied upon by HPPC and all HPPC Related Parties until such time as HPPC is
notified in writing at its address set forth below that this Campaign Release Form is canceled. Any such notice of cancellation
shall be effective only with respect to acts or omissions first occurring after the later of (a) the date of HPPC’s receipt of such
notice of cancellation, or (b) the date Participant completes and returns from any Campaign in which Participant is participating
at the time such notice of cancellation is delivered.
I, the Participant named herein, am eighteen (18) years of age or older, and competent to sign this Campaign
Release Form. This Campaign Release Form is binding on me and my executor, administrators and heirs. This
Campaign Release Form shall apply to any and all Campaigns (present or future) in which Participant participates or
will participate, and in the event of any inconsistency or ambiguity between this Campaign Release Form and any
prior release form signed by Participant, this Campaign Release Form shall control.
I AM AWARE THAT FOREIGN TRAVEL, INCLUDING TRAVEL TO AND FROM ANY CAMPAIGN SITE
LOCATION, HAS INHERENT DANGERS THAT POSE A RISK OF HARM OR INJURY, INCLUDING, BUT NOT
LIMITED TO, DISEASE, LACK OF PROPER HEALTHCARE, CRIME, CIVIL UNREST, LACK OF PROPER
HEALTH STANDARDS, AND LACK OF AIRPORT SECURITY.
I AM AWARE THAT I MAY SUFFER BODILY INJURY OR PROPERTY DAMAGE ARISING OUT OF MY
PARTICIPATION IN THE CAMPAIGNS. HOWEVER, I VOLUNTARILY CHOOSE TO ASSUME THESE RISKS
AND PARTICIPATE IN THE EVENT. I HAVE FULL KNOWLEDGE OF THIS DOCUMENT’S LEGAL
SIGNIFICANCE.
I HAVE FULLY READ THE ABOVE AND UNDERSTAND IT AND HEREBY CONSENT TO IT AND AGREE TO BE
BOUND BY IT.
_______________________________
Witness
_______________________________
Date
____________________________________
Signature
____________________________________
Printed Name of Participant
Address for Notice to Participant:
Address for Notice to HPPC:
_______________________________
3821 University Blvd
_______________________________ Dallas, TX 75205
_______________________________
Attn: Judi Wheeler
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