Name *

First Name

Last Name

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

MM

DD

YYYY

Emergency Contact #1

First Name

Last Name

Emergency Contact #2

First Name

Last Name

Pastoral Reference

First Name

Last Name

Personal Reference #1

First Name

Last Name

Phone

(###)

###

####

Personal Reference #2

First Name

Last Name

Phone

(###)

###

####

Primary Physician

First Name

Last Name

Phone

(###)

###

####

Have you had any major illness during the past two years?

Yes

No

Do you take any medication regularly?

Yes

No

Do you have any special dietary concerns (food allergies, diabetic, etc)?

Yes

No

Please describe any other medical conditions you have that might need special attention?

Yes

No

Are you up to date with vaccinations/immunizations?

Yes

No

Are you willing to take vaccinations/immunizations required for travel?

Yes

No

How would you rate your overall physical condition?

Excellent

Good

Average

Fair

Poor

Do you have any physical problems that would hinder your activity?

Yes

No

If I am accepted by Faith in Action, then...

I commit to follow the directives of Faith in Action leaders and local pastors in a willing and cooperative manner

I commit to put Christ first and set aside my own personal agendas in order to reach the team objectives

I commit to abide by the Faith in Action Code of Conduct

Medical Consent Agreement Acceptance

I DO accept the "Medical Consent Agreement" below

I DO NOT the "Medical Consent Agreement" below

Release of Liability Acceptance

This form is an acknowledgment of short/long term foreign outing Responsibility, Express Assumption of Risk, and a Release of Liability. I understand that during my participation in Faith In Action ministries and foreign outreaches, I may be exposed to a variety of hazards and risks, foreseen or unforeseen, which are inherent in each outing experience and cannot be eliminated without destroying the unique character of the ministry. These inherent risks include, but are not limited to, the dangers of serious personal injury, property damage, and death ("Injuries and Damages") from exposure to the hazards of travel and living in Guatemala. Faith In Action and the field mission directors have not tried to contradict or minimize my understanding of these risks. I know that Injuries and damages can occur by natural causes or activities of other persons, animals, trip members, trip leaders, assistants, and/ or third parties, either as a result of negligence or because of other reasons. I understand that risks of such injuries and damages are involved in adventure travel such as ministry outreaches and I appreciate that I may have to exercise extra care for my own person and for others around me in the face of such hazards. I further understand that on any outing there may not be rescue or medical facilities or expertise necessary to deal with the injuries and damages to which I may be exposed or incur. In consideration for my acceptance as a participant on any outing, and the services and amenities to be provided by the ministry in Guatemala in connection with the outing, I confirm my understanding that: I have read any rules and conditions applicable to the outing made available to me; I will pay any costs or fees for the outing or accorded during the outing; and I acknowledge my participation is at the discretion of the group leader. I understand that I am personally responsible for all risks associated with this travel both medically and financially. This also applies to any incident resulting from transportation provided by Faith In Action in Guatemala during any outing. I agree to assume full financial responsibility in case of accidents resulting in injury, illness or death. This Agreement is intended to be as broad and inclusive as is permitted by law. If any provision or any part of any provision of this agreement is held to be invalid or legally unenforceable for any reason, the remainder of this agreement shall not be affected thereby and shall remain valid and fully enforceable. To the fullest extent allowed by law, I agree to WAIvE, DISCHARGE CLAIMS, AND RELEASE FROM LIABILITY Faith In Action minis- tries, its officers, directors, employees, agents, and leaders from any and all liability on account of, or in any way resulting from Injuries and Damages, even if caused by negligence of Faith In Action or its officers, directors, employees, agents, and lead- ers, in any way connected with this outing. I further agree to HOLD HARMLESS Faith In Action, its officers, directors, employees, agents, and leaders from any claims, damages, injuries or losses caused by my own negligence while a participant on any outing. I understand and intend that this assumption of risk and release is binding upon my heirs, executors, administrators and assigns, and includes any minors accompanying me on any outing. I have read this document in its entirety and I freely and voluntarily assume all risks of such Injuries and Damages and notwithstanding such risks, I agree to participate in this ministry as either a long term helper or a short term visitor.

I DO accept the "Release of Liability Agreement" above

I DO NOT accept the "Release of Liability Agreement" Above

Application Agreement & Signature

By signing my name below, I hereby AGREE that my typed name constitutes the acceptance of the "Commitments", the "Medical Consent", "Code of Conduct" and the "Release of Liability" sections of this form.

Date

MM

DD

YYYY