JESUS IN HAITI MINISTRIES Mission Trip Application and Personal Agreement (PAGE 1 OF 3)
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1 RETURN AS SOON AS POSSIBLE TO: JiHM Trips, c/o Lifepointe Church, 1616 West St, Woodland, CA Group Leaders: Please gather ALL pages for every participant and mail in one envelope to above address - OR - scan and to: trips@jesusinhaiti.org JESUS IN HAITI MINISTRIES Mission Trip Application and Personal Agreement (PAGE 1 OF 3) INSTRUCTIONS (READ BEFORE COMPLETING): You MUST return ALL 3 pages of the JiHM Personal Agreement Form. Be sure to initial EACH page of the agreement. You MUST also read and sign the included Bel Fle hotel form. JiHM will communicate with the hotel on your behalf you just need to SIGN the last page and return it with the 3 pages of the JiHM agreement. Return to your group leader so all forms are mailed together. Please print clearly or type. TRIP DATE LEADER S NAME YOUR NAME (AS IT APPEARS ON YOUR PASSPORT) DATE OF BIRTH ADDRESS STREET CITY STATE ZIP CELL PHONE ALTERNATE PHONE ADDRESS SCHOOL OR OCCUPATION IF IN SCHOOL, LIST YEAR AND MAJOR CHURCH NAME PASTOR S NAME SPECIAL SKILLS OR TALENTS (IE. TEACHING, MUSIC, TRADE, PROFESSION) MEDICAL CONDITIONS/ALLERGIES PAGE 1 OF 3
2 JESUS IN HAITI MINISTRIES Mission Trip Application and Personal Agreement (PAGE 2 OF 3) The guidelines listed below are recommended for those participating in this mission trip. This agreement does not replace requirements that your church or organization may have for you. You go not as a tourist, but as a guest of another country. You may not have the same conveniences you are used to at home. It is very important to be flexible and willing to adjust to the expectations of your host. We have a long-term commitment to the community we serve in Haiti and will not jeopardize our reputation with a short- term group. I accept the following guidelines and agree to the following: 1. I will go as a servant-disciple of Jesus Christ and will adopt that attitude when dealing with my fellow team members and the people I meet during the trip. I realize that others during the trip will look at me for an example of how a Christian acts, and I will not treat that responsibility lightly. I understand that travel can be difficult, and I promise to have a flexible attitude and be supportive. 2. While I am on this trip, I will adopt an attitude of understanding. I will respect the home country, their culture and not try to convince them of my own viewpoint or style. 3. I acknowledge that by engaging in this journey, I am subjecting myself to certain risks voluntarily, including and in addition to those risks that I normally face in my personal and professional life, including, but not limited to such things as health hazards due to poor food and water, diseases, pests, and poor sanitation, potential danger from lack of control over local population, potential injury while working and inadequate medical facilities. I freely assume all such risks. 4. I will abstain from making derogatory comments or arguments regarding people, politics, sports, religion, race or traditions. 5. I understand that our team s work is a tiny part of the bigger picture that JIHM is trying to accomplish. I will respect the advice I am given concerning attire, eating and drinking, and other such traditions. I promise not to be overly demanding, to do my best not to offend or cause embarrassment for the local mission host, and to do my best to help them attain their long-term goals. 6. If a loved one or dear friend is traveling with me, we agree to interact with all the members of the team, not just one another. I promise not to initiate or seek new romantic relationships with team members or locals during the trip. 7. I will abstain from using tobacco or alcoholic beverages while in Haiti and during all travels, including flights to and from Haiti. I will abstain from any illegal drugs or prohibited activity while on this trip. 8. I will refrain from giving large gifts, such as money, clothes, jewelry, electronics, etc. Although the intent of the giver is good, the result after we leave will cause problems for our hosts, and jealousy and bitterness among the locals. If I feel compelled to give a gift to someone I have met, I will consult first with a host missionary before I promise to give the gift. I promise to let him/her make the final decision on the matter. 9. I agree that in the event my conduct is considered so unsatisfactory that it jeopardizes the success of the trip, that my services in connection with this mission trip shall end and I shall return home immediately at my own expense. 10. I am responsible for the cost of the airline ticket once they have been purchased whether they are used or not used for whatever reason. 11. I will raise funds for this trip by asking for financial support from friends and family, using personal finances and/or through fundraising drives. 12. In case of a medical emergency, I authorize my trip leader or JIHM staff to make decisions to allow me the best possible care. 13. I give permission for JiHM to use mission trip photos or videos of me and/or my child, including under any guardianship, in any JiHM materials. PAGE 2 OF 3
3 JESUS IN HAITI MINISTRIES Mission Trip Application and Personal Agreement (PAGE 3 OF 3) 14. In signing below, I represent that I am 18 years of age or older and accept the above conditions. Persons under 18 must have this signed by their parent or guardian. 15. I HEREBY RELEASE, HOLD HARMLESS, AND PROMISE NOT TO SUE JIHM or any individual or organization in any way involved with this trip including any officers, employees, or agents (collectively Releasees ) with respect to any and all bodily injury and/or other loss resulting from participation, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE DURING ANY aspect associated with participation on this trip. This release includes claims arising from strict product liability or resulting from any breach of any express or implied warranty by any Releasee. This Release does not release any Releasee from any liability caused by the Releasee s intentional misconduct or from any other liability that cannot be effectively released under applicable law. I HEREBY AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS THE RELEASEES AND EACH OF THEM FROM ANY LOSS, LIABILITY, DAMAGE, OR COST THEY MAY INCUR ARISING OUT OF OR RELATED TO MY PARTICIPATION ON THIS TRIP, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE. I hereby agree this Agreement shall be binding upon and enforceable against me, my personal representatives, spouse, assigns, heirs, and next of kin without limitation. SIGNATURE I have read this Agreement, fully understand its terms, understand that I have given up substantial rights by signing it, and have signed it freely and voluntarily without any inducement, assurance, or guarantee being made to me and intend my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law. PRINT NAME SIGNATURE SIGNATURE OF PARENT/GUARDIAN (IF PARTICIPANT IS UNDER AGE 18) If participant is under age 18 the undersigned parent/guardian of the above referenced participant has read this Agreement and fully understands its terms and understands that I have given up substantial rights of myself and my child by signing it and having signed it freely and voluntarily without any inducement, assurance, or guarantee being made to me, intend my signature represent my consent to participating in the trip and unconditionally release all liabilities to the greatest extent allowed by law. PRINT NAME OF PARENT/GUARDIAN SIGNATURE OF PARENT/GUARDIAN EMERGENCY CONTACT NAME RELATIONSHIP ADDRESS PHONE STREET CITY STATE ZIP ALTERNATE PHONE PAGE 3 OF 3
4 #12 Rue MBC, Bon Repos, La Plaine, Port-au-Prince, Haiti
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JESUS IN HAITI MINISTRIES Mission Trip Application and Personal Agreement (PAGE 1 OF 3)
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Application for Admission to the Rust College Living Into Our Future Youth Theology Institute for Rising High School Juniors and Seniors
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Get!a!Grip:!Fall!2018! Information*and*Form*Package*
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4-H SHOOTING SPORTS COACH CERTIFICATION TRAINING
TEXAS 4-H YOUTH DEVELOPMENT September 10, 2015 MEMORANDUM TO: FROM: SUBJECT: 4-H Shooting Sports Coach Candidates Laura A. Huebinger Extension Program Specialist 4-H Youth Development 4-H SHOOTING SPORTS
First Name: Middle Initial: Last Name: Gender: D.O.B: / / Age: Years of YMCA Camp Participation: Address: Apt/Unit #:
Camp Location: Camper Grade 2017-18 School Year: Does your camper require any special needs identified through Section 504 (I.D.E.A or an I.E.P)? Yes No If yes, please explain: Camper Grade 2018-19 School
Ogden Cycle Association Membership Agreement
Date: Ogden Cycle Association Membership Agreement Membership Type: (mark all that apply) Single Family Non-Wor king Charter Life Cash / Check # Amount Paid $ Receipt # New Member / Annual Renewal I agree
6. Waiver of Liability and Indemnification University Sponsored International Travel by Students
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Tractor Safety Certification
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COOPERATIVE YOUTH LEADERSHIP CAMP. PERSONAL INFORMATION Questionnaire and Application (Please print or type use additional paper as necessary.
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