FaithWorks
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Destination and date of the trip you are applying for
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Name Occupation
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Preferred first name Date of Birth
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Current mailing address City, State, Zip
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Permanent mailing address City, State, Zip
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E-mail Gender
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Home phone Work phone Cell phone
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Name and address of the local church you attend
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Health insurance company Policy number Blood type
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Insurance contact phone number
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Does your health insurance cover you out of the country? ____ yes ____ no If not, participants must supply supplemental coverage through FAITHWORKS
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Name of your personal physician Physician’s phone number
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List any medications you regularly use including dosage, conflicting medications, contraindications, or any other information which would be helpful during an emergency
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List allergies to food, medication, insects, or other items
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List any physical limitations or conditions which may affect your participation in this ministry
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Medical practice or field of medicine _____________________________________________________________________________________________
Please list the current medical license(s) and/or other credentials you hold _____________________________________________________________________________________________
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How did you hear about this trip? ________________________________________________________________________________
Please provide us with one local professional reference _____________________________________________________________________________________________
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Emergency Contact Information
Name Relationship to you
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Address City, state, zip
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Home phone Work phone
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Cell phone E-mail
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Privacy Information
The information on this form will help us respond appropriately in the event of an emergency. All information will remain completely confidential. Your group leader is the only person outside this office who will have access to personal details.
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Liability Release
Representatives of FaithWorks and your host will do everything reasonably possible to ensure the health and safety of every individual participant in our programs. However, travel and volunteer work have inherent risks such as accidents, injuries, or illness. To limit these risks, participants must have health insurance which applies in full while traveling, and we encourage participants to take practical measures to ensure their own safety and health while traveling. Nevertheless, it is impossible for any organization to cover the potential liability for travel programs. Therefore, we ask that each participant acknowledge the potential risks to person or property and release FAITHWORKS from liability related to illness, accident, injury, death, or loss or damage to one’s belongings while participating in this program. Please complete this form and return it to your group leader. The following release applies to FAITHWORKS and any or all of its partners and representatives. You may wish to review this document with your own attorney to further understand its applications and limitations.
Affidavit of Liability Release
I fully understand the potential personal and property risks associated with travel and volunteer service. I certify that I am participating in this program of my own volition. I certify that I have read the orientation materials, specifically information on health and safety, and I accept complete responsibility for abiding by the safety and health recommendations provided by FAITHWORKS and all of the directions and judgments of the group leader. I understand and agree that I shall take full and complete responsibility for all of my own actions and shall accept complete responsibility for the payment of any damages or injuries that may result from them. I understand that FAITHWORKS assumes no liability for any personal harm, illness, or death that may come to me and assumes no liability for loss or damage to any property. I, my heirs, personal representatives and assigns, in consideration of my admission to this program hereby absolve FAITHWORKS and its present or future members, officers, directors, agents, designated group leaders, and employees and hold them harmless from any claim or demand which I or my heirs, personal representatives, or assigns might conceivably assert for any such accident, injury, illness, death, or property loss or damage. I, the undersigned, have read this release and waiver and understand all of its terms. I execute it voluntarily and with full knowledge of its significance. I certify that I am over the age of 18 years and, therefore, am legally qualified to sign this release and waiver agreement.
Participant Signature_______________________________________________________________________________
Printed Name Date
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For participants who are under 18 years of age, a parent or guardian must sign this form, consenting to the terms of this affidavit of liability release on behalf of a qualified dependent
Signature of Parent or Guardian______________________________________________________________________
Printed Name of Parent or Guardian
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Relationship Date
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Thank you for participating in this ministry. We hope this will be a rewarding and meaningful experience in humanitarian service. Your signature below obligates you to meet all costs and deadlines, to participate in the program in a professional and responsible manner, to conduct all relationships within this program with respect for the value and diversity of cultures, customs, gender, and race of other volunteers and local citizens. Delays in providing information for travel, visas, or payments may incur significant additional costs. Please contact your team leader if you have any questions about cost, deadlines, travel, or preparation.
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