Dear K2K Mission Team Applicant, Bwana Asifiwe! Thank you for thinking about joining us for the K2K Mission trip in June of 2016. We are very excited to be taking a Community Team, a Medical Team and a College Team! An application form and supporting documents are included with this letter. Apply for a passport immediately! Please keep this first page for your records and submit the application portion of this document (page 2 and supplemental documents) to K2K at the following address: K2K Episcopal Diocese of Kansas 835 SW Polk Street Topeka, KS 66611 Community Team and Medical/Dental Team applications must be received by December 1, 2015. Team costs and travel dates for the 2016 trip are as follows: Community Team: June 16 29 $3,800 Medical/Dental Team June 23 July 4 $4,000 Payment Schedule: Fees may be paid in full or in payments noted below: By December 1, 2015 $ 400 All teams By February 20, 2016 $2,000 All teams for airfares By May 7, 2016 $1,400 Community Team $1,600 Medical/Dental Team Fundraising is your responsibility, but we will help you strategize. Two to three mandatory team meetings will be held with the time and date provided by your team leader. Mungu aku Bariki! (The Lord bless you!) Joe Bob & Nyakio Lake Community Leaders Diane Kruger & Pat Parker Medical and Dental Team Leaders
Kansas 2 Kenya Mission Team Application Please fill out this form clearly and legibly. Full Legal Name (As it appears on your Passport): Preferred Name (What do you want to be called?): Home Address: (Street) (City) (State) (Zip) Email Address: Cell Phone Number: Do you text? Yes No Languages spoken (other than English) Previous mission experience Professional Experience: Role/Specialty: If Student Field of Study: Year: Freshman Sophomore Junior Senior Grad Student Date of Birth: Age on May 24, 2016: Gender: Male Female Emergency Contact: Name: Relationship: Phone Number: Complete and attach the following documents: Medical information form Information questionnaire college team only Consent, Indemnification, Release, and Waiver of Liability form 2 copies of passport Immunization record
Medical Information Name Please list health problems/notes as appropriate: Please list allergies and nature of reactions: Allergy Reaction Please list medications and doses taken:
Consent, Indemnification, Release, and Waiver of Liability As of the date written below, the undersigned (the Releaser ) acknowledges that I have voluntarily applied to participate on a service-based trip (the Trip ) with Kansas 2 Kenya (K2K), as part of the non-profit Episcopal Diocese of Kansas. K2K is an organization providing assistance in arranging the Trip, which involves travel to, and volunteer work in the United States or foreign countries. For being permitted by K2K to participate in the Trip, for K2K assisting in arranging the Trip, and for other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, I hereby agree to the following: 1. I do hereby CONSENT to myself or my child s participation in programs and ministries to Africa or elsewhere with K2K and do hereby assume all of the risks associated with such participation and travel to countries outside of the United States, and am aware of such risks. 2. I understand that this document is a release, indemnification and a waiver of liability for the benefit of K2K. And that by signing this document I am assuming the risks of traveling to and working in such foreign countries as K2K may select in order to carry out their mission. I understand that I will be traveling and working in areas where health and sanitation practices may be below United States standards. I also understand that there are certain risks inherent in air travel and travel to nations outside of the United States, including but in no way limited to the following: death, illness, terrorism, inadequate medical facilities, crime, political instability, governmental opposition to project activities, as well as similar and dissimilar risks. 3. I understand that K2K will not be held responsible for any additional cost, loss of airfare deposits, or losses due to flight schedule changes or cancellation, whether by me or by airline, including connecting flights. I understand and agree that there will be no deviation in travel itineraries to any other destinations unless previous arrangements are investigated and approved by K2K in K2K s sole discretion well in advance of the Trip. I also understand that any deviation from the group itinerary for additional tourism is specifically NOT authorized by K2K and I agree not to do so without K2K s explicit, written approval. (Trip cancellation insurance is available at an extra cost, if you choose.) 4. I understand that passports and visas are required for international travel and that it is my responsibility to obtain the necessary travel documents. K2K will not be held responsible for any loss of travel cost due to lack of obtaining these documents. 5. I acknowledge that I have completely read and understand this document. I am signing this document freely and voluntarily and without any coercion or any influence of any kind. I acknowledge that there have been no promises, representations or inducements to my signing this document other that those set forth herein. 6. I DO HEREBY INDEMNIFY, RELEASE, WAIVE LIABILITY, FOREVER DISCHARGE, AND COVENANT NOT TO SUE OR ATTACH THE PROPERTY OF K2K, THE EPISCOPAL DIOCESE OF KANSAS, INC., AND ALL OF THEIR OFFICERS, DIRECTORS, VOLUNTEERS, AND ANY PERSONS CONNECTED THEREWITH (COLLECTIVELY, THE RELEASEES ), FROM ALL CLAIMS OF ANY NATURE NOW OR HEREAFTER EXISTING WHETHER KNOWN OR UNKNOWN, INCLUDING BUT NOT LIMITED TO ALL LIABILITY, ON ACCOUNT OF DEATH, INJURY, OR DAMAGE RESULTING FRO THE NEGLIGENCE OR OTHER ACTS,, HOWEVER CAUSED, OF THE RELEASEES AS A RESULT OF MY PARTICIPATION IN THE TRIP AND FROM ANY AND ALL LOSS, LIABILITY, ACTIONS, CLAIMS AND DEMANDS OF ANY NATURE PAST, PRESENT OR FUTURE, THAT MAY RESULT FROM OR BE IN ANY WAY RELATED TO MY OR MY CHILD S ACTIVITIES CONDUCTED UNDER THE AUSPICES OF K2K. I UNDERSTAND THAT THE RELEASEES MAY HEREAFTER MAKE MISTAKES, COMMIT ACTS, OR OTHERWISE FAIL TO DO THINGS, THROUGH THEIR OWN NEGLIGENCE OR OTHERWISE, WHICH MAY CAUSE MY DEATH, INJURY, ILLNESS OR LOSS OF PROPERTY OR OTHER SERIOUS HARM. I HEREBY ASSUME ALL RISK AND WAIVE ANY AND ALL DAMAGES, COMPENSATION OR OTHER REMUNERATION FROM K2K FOR ANY LOSS. I UNDERSTAND THAT I AM ALSO INDEMNIFYING THE RELEASEES FROM ANY AND ALL LIABILLITY WHICH ARE A RESULT OF MY ACTIONS DURING THE COURSE OF MY VOLUNTEER SERVICES WITH K2K (IE) CONSULTANT OR K2K EMPLOYEE. FURTHER, I HEREBY WAIVE ANY AND ALL CAUSES OF ACTION WHICH I HAVE NOW OR WHICH MAY ARISE IN THE FUTRE AGAINST RELEASEES, NOTWITHSTANDING THE FOREGOING, ANY DAMAGES OR CAUSES OF ACTION WHICH ARISE FROM INTENTIONAL OR WILLFUL MISCONDUCT ON THE PART OF THE RELEASEES IS EXPLICITLY NOT WAIVED OR RELEASED BY THIS DOCUMENT. Consent, Indemnification, Release, and Waiver of Liability
Page 2 7. I hereby consent to any background checks which K2K may wish to undertake prior to accepting my application to participate in a Trip. I understand that any record or indication of (1) criminal sexual conduct or an adult or minor, (2) neglect of a child, or (3) physical abuse will bar me from participating, in K2K s sole and absolute discretion. 8. I understand that I am personally required to and responsible for providing my own insurance coverage of any and all types, including but not limited to: medical, medical evacuation, kidnapping, hospitalization,, life, disability, death, lost baggage, lost or stolen personal property, and any and all other insurance which I may need or desire. I understand and agree that K2K is in no way required to provide me with insurance of any kind. I understand that K2K may provide and require me to purchase insurance of K2K s choosing as a condition to participate on any Trip, but that K2K is in no way required to do so. 9. I hereby agree and consent that K2K may remove me from any Trip or otherwise prevent my participation in any Trip if K2K feels that I am creating a risk of any kind, in K2K s sole and absolute discretion. I have carefully read this Agreement and fully understand its contents. I am aware that this is a release of liability of all the Releasees and a contract between myself and K2K. No oral representations, statements or inducements have been made to me apart from this document. I sign this document of my own free will on the day of in the year. RELEASOR: K2K: Kansas to Kenya; part of Episcopal Diocese of Kansas Signature By: Printed Name Printed Name: Guardian (if under 18) Printed Name