International Waiver and Release

• International Location*
  >Choose One:CubaHaitiNicaraguaCosta RicaPanamaPhilippinesBrazilIsrael
• Trip Date*
• PERSONAL / MEDICAL INFORMATION
  I affirm that the information listed below is complete and accurate to the best of my knowledge.
• Name as it appears on Your Passport*
  Please enter name exactly as it appears on your Passport
• Name you go by
• Date of Birth*
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• Birthplace
• Citizenship*
• Address*
  Street Address*

  Address Line 2

  City*

  Province / State / Region*

  Postal Code / Zip

  Antigua and BarbudaBahamasBarbadosBelizeCanadaCosta RicaCubaDominicaDominican RepublicEl SalvadorGrenadaGuatemalaHaitiHondurasJamaicaMexicoNicaraguaPanamaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesTrinidad and TobagoUnited StatesArgentinaBoliviaBrazilChileColumbiaEcuadorGuyanaParaguayPeruSurinameUruguayVenezuelaAlbaniaAndorraArmeniaAustriaAzerbaijanBelarusBelgiumBosnia and HerzegovinaBulgariaCroatiaCyprusCzech RepublicDenmarkEstoniaFinlandFranceGeorgiaGermanyGreeceHungaryIcelandIrelandItalyLatviaLiechtensteinLithuaniaLuxembourgMacedoniaMaltaMoldovaMonacoMontenegroNetherlandsNorwayPolandPortugalRomaniaSan MarinoSerbiaSlovakiaSloveniaSpainSwedenSwitzerlandUkraineUnited KingdomVatican CityAfghanistanBahrainBangladeshBhutanBrunei DarussalamMyanmarCambodiaChinaEast TimorIndiaIndonesiaIranIraqIsraelJapanJordanKazakhstanNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLebanonMalaysiaMaldivesMongoliaNepalOmanPakistanPhilippinesQatarRussiaSaudi ArabiaSingaporeSri LankaSyriaTaiwanTajikistanThailandTurkeyTurkmenistanUnited Arab EmiratesUzbekistanVietnamYemenAustraliaFijiKiribatiMarshall IslandsMicronesiaNauruNew ZealandPalauPapua New GuineaSamoaSolomon IslandsTongaTuvaluVanuatuAlgeriaAngolaBeninBotswanaBurkina FasoBurundiCameroonCape VerdeCentral African RepublicChadComorosCongoDjiboutiEgyptEquatorial GuineaEritreaEthiopiaGabonGambiaGhanaGuineaGuinea-BissauCôte d\'IvoireKenyaLesothoLiberiaLibyaMadagascarMalawiMaliMauritaniaMauritiusMoroccoMozambiqueNamibiaNigerNigeriaRwandaSao Tome and PrincipeSenegalSeychellesSierra LeoneSomaliaSouth AfricaSudanSwazilandTanzaniaTogoTunisiaUgandaZambiaZimbabwe

  Country*
• Phone*
  Best number to reach you. Cell phone number preferred
   

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• Your Email*
   
• Marital Status*
  >Choose One:SingleMarried
• Gender*
  >Choose One:MaleFemale
• Passport Number
• Country Issued
• Expiration Date
  Must be valid at least six months prior to trip start date. If not, you must submit for a new passport.
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• T-Shirt Size*
  Small

  Medium

  Large

  X-Large

  XX-Large

  XXX-Large
• Emergency Contact Name and Number*
• Do you have any medical condition(s) that we should be aware of? If so, please list details below.
• Are you taking any medication that we should be aware of? If so, please list details below.
• Insurance Company
• Group Number
• Primary Policy Holder's Name
• Policy Number
• Additional Question/Comments
• ACKNOWLEDGMENT, ASSUMPTION, and RELEASE
  Please read the following agreement and waiver carefully. It includes releases of liability and waiver of legal rights, and deprives you of the ability to sue certain parties. By agreeing electronically, you acknowledge that you have both read and understood all text presented to you as part of the registration process.
  
  I, the undersigned, wish to participate in a short-term mission project in the country selected above conducted under the auspices of Hope Missions. By signing this form, I acknowledge (1) that travel to and in the country selected above involves hazards not customarily encountered when traveling in America. (2) Medical facilities in the country listed above are substandard and that should a medical emergency develop during my trip, it is unlikely that I will receive medical care in the country listed above equivalent to that available in America. (3) Working conditions in the country listed above are often inferior to conditions in America. (4) Hope Missions does not carry insurance to insure against any of the risks I may encounter in the country listed above.
  
  Despite the foregoing, it is my desire to participate in the work in the country selected above, and I knowingly assume the risks that are involved and release Hope Missions, its employees and agents, from any liability for injury, damage, or harm which may occur to my person or property while traveling in connection with this project or otherwise participating in this project.
  
  I affirm that I am eighteen (18) years of age or older, or the parent/guardian of the participant if under eighteen years of age, and that this Acknowledgment, Assumption, and Release is binding on me and my executor, administrators, and heirs. I give Hope Missions and it's representative(s) with me on any such trip authority to request and authorize medical and/or hospital treatment for my benefit in the event of any injury or sickness sustained by me while on such ministry activity, including, without limitation, while traveling to and from any foreign country. I agree to pay for all such treatment and to reimburse Hope Missions for all costs and expenses incurred by it with respect to such treatment.
  
  By entering my name below, I assert that I have reviewed and agree to all of the waivers and agreements above.
• Electronic Signature - Full legal name*
• By checking below you are agreeing to a digital signature and acceptance*
  Agreed to and Accepted
• Today's Date*
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