Global Trip Application
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Global Trip Application 

Global Trip Application for

Personal Information

First Name
Last Name
Your Email
Phone Number
Street Address
City, State, Zip Code
T- Shirt Size
Birthdate
Today
Country of Citizenship
Do you have a valid passport?

Passport Information

Passport Number
Date issued
Today
Expiration date
Today
Name as it appears on your passport

When can you have one?

Spouse's name if applicable

Medical History

Please describe your general health
Please list any limitations
Please list any medical or physical restrictions
Please list any medications
Please list any allergies (food, drugs, or other)
Please list any medications used to treat allergies
Date of your last Tetanus shot
Today
Medical treatment received in the past year
Have you been exposed to any contagious diseases in the past six months? If so, what?
Physician's Name
Office Phone
Office Address
City, State, Zip Code

Consent

I hereby give permission for my son / daughter / self (if over 18 years of age) to receive emergency medical attention from a physician in the event of illness or injury. (Please check one.)
Electronic Signature*
Date
Today

Insurance

Insurance issued in the name of
Address of insured
City, State, Zip Code
Name of insurance company
Address of insurance company
City, State, Zip Code
Policy number
Beneficiary

Involvement

Check if applicable
Please list the ministries teams with which you have been involved at The Cove:
Please list any previous trips or OutREACH experience:
I authorize The Cove Church to verify all data given by me on the release form above. I understand a thorough investigation may be conducted which may include but not be limited to criminal history, residence verification, and motor vehicle driving record. Furthermore, I release all agencies, bureaus, information service organizations, and courts named above from all liabilities or damages that might result from information provided in good faith. I state that the information provided by me on this form is accurate. I understand that the information requested below regarding sex, race and date-of-birth are for the sole purpose of gathering the above information accurately and will not be used to discriminate against me in violation of the law. A facsimile (FAX) or photocopy of this authorization shall be as valid as the original.
Participant's Electronic Signature (or Guardian if under 18)
Any funds raised or account balances are non-refundable. In the event of trip cancellation or rescheduling: all money will remain in an account, under the applicant's name, for one year to be used for the next global trip.

Liability Release Form of all claims

In consideration for being accepted by The Cove Church for participation in OutREACH events from January 2015 through December 2015, I do hereby release, forever discharge and agree to hold harmless The Cove Church and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the child-participant that occur while said child is participating in the above described trip or activity. Furthermore, I hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. Further, authorization and permission is hereby given to said church to furnish any necessary transportation, food and lodging for this participant.

The undersigned further hereby agree to hold harmless and indemnify said church, its directors, employees and agents, for any liability sustained by said church as the result of the negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto.

Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, we (I) hereby assume all transportation costs.
Electronic signature
Todays date
Today

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