El Salvador/Guatemala Trip Dates: July 31- Aug 10 Please print in ink (Or type and e-mail) El Salvador Mission/Study Trip Application Name: Age: Birthday: LAST FIRST MIDDLE Male Female Email Address City State Zip Phone Pager / cell Emergency contact Phone: Home Work Church Name 1. What is the best way to contact you? 2. Do you have health or dietary concerns we as leaders of the trip should be aware of? 3. Why do you want to come on this trip? 4. What talents, skills, knowledge, or gifts do you bring to the group and to the trip? picture taking movie making music. Which instruments? administration children s ministry medical work, what specialization? computer maintenance/connections for donated computers? connections for medical/health supplies? describe handy/repair skills, construction skills other? 5. What projects particularly interest you? (check all that apply) Building/Construction Dental/Medical Mission Helping Pastoral Team (Matias) School/Children s Ministry Helping in Guest House Hope House Homeless Ministry 6. Do you commit to participating in all scheduled group gatherings and devotions during the mission trip, including during our August 8-10 th stay in Antigua, Guatemala? YES NO 6. Is there anyone else you would like Julie to send more information to? If so, place their information. (complete name, address, phone, email) Please mail to us: This Application Form for each participant Emergency Contact/Medical Info for each participant Waiver and Medical Release Form for each participant (there s a different one for minors, along with a letter that must be filled out an notarized for children travelling without a parent) Photocopy of the first photo page of your passport $200 Non-Refundable Deposit Check made out to Julie Jacks (please send by mail) And send to: Julie Jacks, 505 Larsson Street, Manhattan Beach, CA 90266 If you have any questions, feel free to call Julie at: 310-798-9081 Thank you! Muchas Gracias!
Emergency Contact Information El Salvador and Guatemala Trip My Name: My birthdate, month, year: IN CASE OF EMERGENCY, PLEASE CONTACT: Name: Relationship: Address: City: State: Zip Code: Country: Day phone: ( ) - - Night Phone: : ( ) - - The following information may be needed by any hospital or medical practitioner not having access to your medical history: Allergies to medicine, food, etc. Medication being taken: Date of last tetanus shot: Physical Impairments: Other: PERSONAL PHYSICIAN Name: Relationship: Address: City: State: Zip Code: Country: Day phone: ( )- - Night Phone: : ( )- - PERSONAL HEALTH INSURANCE COVERAGE: Company: Policy Number: Insurance Agent: Agent s Phone: Primary Beneficiary: Relationship: Secondary Beneficiary: Relationship:
RELEASE AND WAIVER OF LIABILITY EL Salvador and Guatemala Mission Trip Important: Each participant must have a signed Release and Waiver of Liability on file. Complete this form now in order to be considered and print all information in blanks provided. This Release and Waiver executed on this day / / (date) by (participant s name) and in effect for one full calendar year from this date. I, the Participant, desire to participate in a mission trip to El Salvador and Guatemala this coming summer in order to grow in faith and accompany the Lutheran Church of El Salvador. I, the participant, understand that the activities may include but are not limited to: traveling to and from other countries, traveling to and from other cities and towns, consuming food and living in accommodations available and provided in the foreign countries, working with the Lutheran Church, assisting at a homeless shelter, participating in a march for human rights, and other church activities. I hereby freely and voluntarily, without duress, execute this Release under the following terms: 1) Waiver and Release. I, the Participant, release and forever discharge and hold harmless the leaders of this mission trip (Pastors Anna-Kari and Kristian Johnson, Julie Jacks), Pilgrim Lutheran Church, Chicago, IL; Resurrection Lutheran Church, Redondo Beach, CA; and their successors and assigns from any and all liability, claims, and demands of whatever kind and nature, either in law or in equity, which arise or may hereafter arise from my participation in this mission trip. I understand and acknowledge that this Release form discharges the leaders of this trip from any liability or claim that I, the participant, may have against them with respect to bodily injury, personal injury, illness, death, or property damage that may result from my participation with a Thrivent Builds Worldwide work team. I also understand that the leaders nor any church involved is assuming any responsibility for or obligation to provide financial assistance or other assistance, including but not limited to: medical, health, or disability insurance, in the event of injury, illness, death, or property damage. 2) Medical Treatment I, the volunteer, hereby release and forever discharge the leaders of this trip from any claim whatsoever which arises or may hereafter arise on account of any first-aid treatment or other medical services rendered in connection with an emergency during my time in El Salvador and Guatemala. 3) Assumption of the risk. I, the participant, hereby expressly and specifically assume the risk of injury or harm in these activities and release the leaders and churches involved from all liability for injury, illness, death, or property damage resulting from the activities of my time with the mission group. 4) Photographic release. I, the participant, grant and convey unto the leaders and congregations involved all right, title, and interest in any and all photographic images and video or audio recordings made by Habitat and Thrivent Financial during my work with this mission group. To express my understanding of this release, I sign here with a witness. Name of Volunteer (please print): Address: City: State: Zip Code: Name of witness (please print): Home Phone: ( ) - Work Phone ( ) -
RELEASE AND WAIVER OF LIABILITY of a MINOR EL Salvador and Guatemala Mission Trip Important: Each participant must have a signed Release and Waiver of Liability on file. Complete this form now in order to be considered and print all information in blanks provided. This Release and Waiver executed on this day / / (date) by (participant s name), a minor child (the participant) and and the parents having legal custody and/or the legal guardians of the Volunteer (the Guardians ) and in effect for one full calendar year from this date. The participant and guardians desire that their child participate in a mission trip to El Salvador and Guatemala this coming summer in order to grow in faith and accompany the Lutheran Church of El Salvador. The participant and guardians understand that the activities may include but are not limited to: traveling to and from other countries, traveling to and from other cities and towns, consuming food and living in accommodations available and provided in the foreign countries, working with the Lutheran Church, assisting at a homeless shelter, participating in a march for human rights, and other church activities. The participant and guardians hereby freely and voluntarily, without duress, execute this Release under the following terms: 1) Waiver and Release. The participant and guardians release and forever discharge and hold harmless the leaders of this mission trip (Pastors Anna-Kari and Kristian Johnson, Julie Jacks), Pilgrim Lutheran Church, Resurrection Church, and their successors and assigns from any and all liability, claims, and demands of whatever kind and nature, either in law or in equity, which arise or may hereafter arise from the participant s participation in this mission trip. The participant and guardians also understand and acknowledge that this Release form discharges the leaders from any liability or claim that the participant, may have against them with respect to bodily injury, personal injury, illness, death, or property damage that may result from my participation with this mission group. The participant and guardians also understand that the leaders nor any church involved is assuming any responsibility for or obligation to provide financial assistance or other assistance to the participant, including but not limited to: medical, health, or disability insurance, in the event of injury, illness, death, or property damage. 2) Medical Treatment The participant and guardians hereby release and forever discharge the leaders of this trip from any claim whatsoever which arises or may hereafter arise on account of any first-aid treatment or other medical services rendered in connection with an emergency during the participant s time in El Salvador and Guatemala. 3) Assumption of the risk. The participant and guardians hereby expressly and specifically assume the risk of injury or harm in these activities and release the leaders and churches involved from all liability for injury, illness, death, or property damage resulting from the activities of the participant s time with the mission group. 4) Photographic release. The participant and guardians grant and convey unto the leaders and congregations involved all right, title, and interest in any and all photographic images and video or audio recordings made by Habitat and Thrivent Financial during the partcipant s work with this mission group. To express our understanding of this release, the participant and guardians sign here with a witness. Name of Volunteer (please print): Signature: Name of Guardian (please print): Signature:
Name of Guardian (please print): Signature: Parental Authorization for Treatment of a Minor Child I,, am the parent or legal guardian having custody of, a minor child. As such a parent or legal guardian, I hereby authorize and appoint Pastors Anna-Kari and Kristian Johnson, adults in whose care the minor child has been entrusted as my agent to act for me with respect to my minor child,, and in my name in any way I could act in person to make any and all decisions for me with respect to my minor child,, concerning my minor child s personal care, medical treatment, hospitalization, and health care and to require, withhold, or withdraw any type of medical treatment or procedure, including X-ray examination, anesthetic, medical, or surgical diagnosis or treatment which may be rendered to my minor child under the general or special supervision and on the advice of any physician or surgeon licensed to practice in the state in which treatment is sought. My agent shall have the same access to my minor child s medical records that I have, including the right to disclose the contents to others. Parent or Guardian: (signature) Date: Parent or Guardian: (signature) Date: THIS RELEASE AND WAIVER OF LIABILITY FOR MINORS AND PARENTAL AUTHORIZATION FOR TREATMENT OF A MINOR CHILD sworn to and subscribed before me by:, and, the parents or legal guardians of, a minor child, this day of, 20. Notary Public Name: My commission expires: Note: