(OS) Mission Trip: Haiti (07/07/12-07/13/12) Liquid

CAREFULLY READ THE FOLLOWING TERMS AND CONDITIONS. IF YOU AGREE WITH THESE TERMS, INDICATE YOUR ASSENT BELOW.

TO DOWNLOAD A PRINTER-FRIENDLY FULL SCREEN VERSION OF THE DOCUMENT SELECT FILE>SAVE AS IN YOUR WEB BROWSER.

TO PRINT A COMPLETE VERSION OF THE DOCUMENT SELECT FILE>PRINT IN YOUR WEB BROWSER.

*PLEASE NOTE THAT AT THE END OF THE REGISTRATION YOU WILL BE REQUIRED TO MAKE A $200 NON-REFUNDABLE DEPOSIT

Question Title

* 1. How did you hear about this trip?

Question Title

* 2. GENERAL INFORMATION:

NAME AS IT APPEARS ON YOUR PASSPORT

(Please note: this is the name we will use for an airline ticket, so it must be EXACTLY as it appears on your passport.)

Name:

Address:

City:

State:

ZIP Code:

Email Address:

Phone Number:

Question Title

* 3. Nickname:

Question Title

* 4. Please check the appropriate box:

Male

Female

Question Title

* 5. Date of Birth:

Question Title

* 6. Age:

Question Title

* 7. Citizen of what country:

Question Title

* 8. PASSPORT INFORMATION:

Do you have a valid passport?

Issued by what country?

Expiration Date of Passport

Passport#

***SPIRITUAL INFORMATION***

Question Title

* 9. What is your home church and how long have you attended there?

Question Title

* 10. What ministries are you involved in at your church?

Question Title

* 11. What are your spiritual gifts?

Question Title

* 12. Name a pastor or leader at your church who could give you a reference (Name and Phone Number).

Question Title

* 13. Name two people who know you and your spiritual walk (Name and Phone Number).

Reference 1

Reference 2

Question Title

* 14. Please Describe how and when you came to know the Lord.

Question Title

* 15. Have you been water baptized?

Yes

If yes, where and when?

Question Title

* 16. Have you ever served on a mission trip or had a cross-cultural experience?

Yes

If yes, where and when?

Question Title

* 17. Please explain why you want to go on this trip.

***WORK EXPERIENCE & RELATED SKILLS***

Question Title

* 18. Please list any relevant medical certifications you have.

Question Title

* 19. Where are you employed and for how long?

Question Title

* 20. Please check all that apply to you.
I speak the following language(s):

English

Creole

French

Spanish

Other

Other (please specify)

Question Title

* 21. Please check all that applies to you.
I have had the following types of training:

Disaster Relief

Missions Training

Chaplain Training

Crisis Counseling/ Biblical Counseling

Vacation Bible School/ Childrens Ministry

Dramas

Construction

Question Title

* 22. Please check all that applies to you.
The mission trip I have attended was with:

Calvary Chapel Fort Lauderdale

Other Church

Other Organization

Other (please specify)

Question Title

* 23. Please check all that apply to you.
I have been part of the following mission trip(s):

construction/working

ministry/evangelical

inter-city/street outreach

touring/study

disaster relief

Question Title

* 24. Please check if you are a

Plane Owner

Pilot

Doctor

Nurse

Paramedic

Fireman

Policeman

Carpenter

Plumber

Electrician

Roofer

Construction/Laborer

Other

Other (please specify)

***PERSONAL INFORMATION***

Question Title

* 25. What are your personal expectations for this trip? What would make this trip a success for you?

Question Title

* 26. Do you consider yourself:

Introvert

Fact Oriented

Extrovert

Perceptive

Intuitive

Feeling

Decisive

Intellectual

Question Title

* 27. How does your family feel about your participation on this trip? Was their Response to your decision enthusiastic, skeptical, negative, or supportive?

Question Title

* 28. Have you been involved with any of the following withing the past year?

	Yes	No
Alcohol	Alcohol Yes	Alcohol No
Tobacco	Tobacco Yes	Tobacco No
Illegal drugs	Illegal drugs Yes	Illegal drugs No
Cult of the occult	Cult of the occult Yes	Cult of the occult No
Criminal activity	Criminal activity Yes	Criminal activity No

If yes, (please specify)

Question Title

* 29. Have you ever been convicted of a crime?

Yes

If yes, please explain

Question Title

* 30. What are the most significant events that have occurred in your life in the past two years?

Question Title

* 31. What do you see as your strongest character quality and why?

Question Title

* 32. What do you see as your weakest character quality and why?

Question Title

* 33. Do you have any questions or concerns regarding this trip that you would like answered at this time?

***HEALTH INFORMATION***

* You may be required to provide a doctor's letter of "clearance" before traveling.

Question Title

* 34. Do you have or have you ever had:

Fainting Spells

Heart Problems

Diabetes

Respiratory Problems

Seizures

Eating Disorder

Other (please specify)

Question Title

* 35. Do you have any conditions that might affect your ability to fully function as a team member on this trip?

fear of flying

depression

anxiety

sleep disorder

Other (please specify)

Question Title

* 36. Do you have any chronic illness or allergies?

Yes

If Yes (please specify)

Question Title

* 37. Are you presently taking medication prescribed by a doctor?

Yes

If yes, (please specify)

Question Title

* 38. Have you ever had any psychiatric care or treatment?

Yes

If yes, (please specify)

Question Title

* 39. Please list any hospitalization History

Question Title

* 40. How would you describe your health and fitness?

Excellent

Good

Average

Below Average

***MEDICAL INFORMATION FORM***

The Center for Disease Control does not require any immunizations to enter Haiti but makes several recommendations. Given that the Center of Disease Control does not require any vaccinations, Calvary Chapel Ft. Lauderdale cannot mandate individual team members be immunized. Therefore, each team member must make his/her own decision regarding their health and well being.

The undersigned, (Participant) acknowledges that I have been informed of the Center for Disease Control’s immunization recommendations which are as follows:
• Routine Immunizations: MMR, DPT, Polio, Varicella, Seasonal Flu and H1N1
• Hepatitis A and B
• Rabies
• Typhoid
• Malaria

It is your responsibility to explore CDC’s website for a full description of recommendations.

http://wwwnc.cdc.gov/travel/content/news-announcements/relief-workers-haiti.aspx

Question Title

* 41. Please List your Blood Type

Question Title

* 42. Please List any known allergies

Question Title

* 43. Please List any known Medical Problems

Question Title

* 44. Medical Insurance Information

Medical Insurance Company:

Phone Number for International Contact:

Policy Number:

Primary Care Dr. If HMO:

Phone Number of Dr.:

***EMERGENCY CONTACT INFORMATION***

Question Title

* 45. Emergency Contact Information:

Name: *

Relationship to you: *

Address: *

City: *

State: *

ZIP: *

Email Address:

Phone Number: *

The undersigned, (the individual, including the individual’s parents or legal guardians, if under 18 years of age) listed in Section 1), (hereinafter the “Participant”) in consideration of my participation in the Calvary Chapel Outreach Ministry 2012 Short-Term Mission Trip to Haiti (hereinafter the “Mission Trip”) and the mutual covenants set forth in this Agreement together with other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the Participant, intending to be legally bound, for myself, my heirs, assigns,executors, and administrators, does hereby waive and release, assume all risks, and agree to indemnify and hold harmless Calvary Chapel Church, Inc., d/b/a Calvary Chapel Ft. Lauderdale and its integrated auxiliaries and controlled organizations, including their directors, officers, staff, volunteers, or representatives and assigns (hereinafter “Calvary Chapel”) from and against any and all claims for death, personal injuries or property damage, costs, expenses and actions of any kind whatsoever, arising out directly or indirectly out of my participation in the Mission Trip,including without limitation liability arising out of negligence or carelessness on the part of Calvary Chapel.

The Participant has voluntarily chosen to participate in the Mission Trip and to be involved in outreach to others by seeking to meet their physical and spiritual needs.The Participant assumes all risk and responsibility for any damage or injury to their property or any personal injury, which the Participant may sustain while involved in the Mission Trip, including any related medical costs and expenses.

The Participant understands that this short-term Mission Trip entails a risk of physical injury and may involve extreme climates, adverse working conditions, hard physical labor and exposure to potentially dangerous areas of the world. The Participant certifies that he or she is in good health and physically able to perform this type of work.Calvary Chapel requires all Participants to be in good physical condition, and may require Participant to obtain a doctor’s exam and prior written approval to participate on the Mission Trip.

The Participant hereby authorizes Calvary Chapel or its representatives to act for the Participant,in their best judgment and in any emergency requiring medical attention. All medical expenses incurred will be the responsibility of the Participant or the Participant's family. The undersigned certifies that the Participant has no physical condition or mental impairment that would be effected by their participation in the Mission Trip. If the Participant is a minor child and the undersigned cannot be reached in an emergency, the undersigned grants permission to any licensed physician, surgeon, clinic, or hospital to secure proper treatment and to order anesthesia,if medically required.

Calvary Chapel will arrange for Participant’s accommodations and the Participant understands that Calvary Chapel is not responsible or liable for Participant’s personal effects and property and that Calvary Chapel will not provide lock up or security for any personal property belonging to the Participant during the Mission Trip. The Participant further agrees to abide by whatever rules and regulations may be in effect for the accommodations during the Mission Trip.

Calvary Chapel requires strict compliance with rules and regulations, including the rules concerning conduct, dress, and Christian lifestyle. These are explained in the Team Covenant, which will be provided to Participant and which Participant agrees to be bound upon acceptance of this Agreement. If a Participant is declined from participation on the Mission Trip, the application fee will be refunded. Failure by the Participant to comply with this Agreement, the Team Covenant or any other rules and procedures related to the Mission Trip are grounds for dismissal, without refund or reimbursement. Should a Participant choose to cancel the trip or is dismissed, all application fees and all sponsor funds received by Calvary Chapel will be deemed contributions and are not refundable.

To receive a tax deduction, the IRS regulations stipulate that the donor must release control of all funds donated to a non-profit organization. For this reason, contributions from sponsors cannot be refunded, nor can they be designated to any specific person. Participants may raise funds and receive credit for these funds equal to the price of his or her trip, less the trip deposit which must be paid by the Participant personally. Each Participant’s trip cost must be paid in full prior to departure. Lack of payment could result in denial of Participant’s attendance on the Mission Trip. Extensive training materials will be provided for all approved Participant’s. It is each Participant’s responsibility to complete any assigned tasks and reading in preparation for participation on the Mission Trip.

The parties to this Agreement are Christians and believe that the Bible commands them to make every effort to live at peace and to resolve disputes with each other in private or within the Christian church (Matthew 18:15-20; 1 Corinthians 6:1-8). Therefore, the parties agree that any claim or dispute arising from or related to this Agreement shall be settled by Biblically-based mediation and, if mediation is not successful, legally binding arbitration in accordance with the Rules of Procedure for Christian Conciliation of the Institute for Christian Conciliation, a division of Peacemaker® Ministries (complete text of the Rules is available at www.Peacemaker.net). The parties shall adhere to the Rules, except that the parties agree to select only one arbitrator and agree to hold any such mediation or arbitration in Broward County, Florida, at a mutually agreed location. (If the parties cannot agree on a mediator, arbitrator, or location within Broward County, Calvary Chapel shall name three persons or locations and Participant shall choose from those three.) Judgment upon an arbitration decision may be entered in any court otherwise having jurisdiction. The parties understand that these methods shall be the sole remedy for any controversy or claim arising out of this agreement and THE PARTIES EXPRESSLY WAIVE THEIR RIGHT TO HAVE CLAIMS ARISING FROM THIS AGREEMENT ADJUDICATED IN A CIVIL COURT, except to enforce an arbitration decision.

Therefore:

1. By clicking the "I Accept" button below, Participant (i) agrees and consents to the terms of the above Agreement electronically; (ii) agrees that use of electronic sounds, symbols, or processes provided by Participant to establish his or her acceptance or agreement to the terms of the above Agreement constitutes Participant’s electronic signature and signifies Participant’s intent to be bound; (iii) consents to receive an electronic record of the terms of the above Agreement in lieu of a hard or paper copy or version thereof; (iv) acknowledges and demonstrates his or her ability to access electronically this Agreement and their satisfaction of the software and hardware requirements necessary; and (v) confirms and represents that Participant, in fact, has accessed and is able to view, save and print any sample electronic Agreement terms.
Participant may click the "Decline" button if he or she does not accept the Agreement terms, but if Participant declines he or she will not be allowed to participate on the Mission Trip.

2. Subject to Participant’s right to withdraw his or her consent and/or obtain paper copies of the Agreement as provided below, in order to enter into the Agreement Participant must consent to receive in electronic form both: (i) the Agreement terms; and (ii) any other information and communications that Calvary Chapel elects to provide to Participant electronically. Participant agrees that the electronic Agreement will be sufficient as a "writing" under applicable law or regulation. In order to access and retain the electronic Agreement terms and Agreement, Participant must have a computer capable of browsing the internet and access to a printer.

3. Participant has the right at any time to withdraw his or her consent to receive the electronic records with respect to the Agreement, and Participant may request and receive a paper copy of the electronic records. If Participant wishes to withdraw such consent, or to request a paper copy of the electronic records, Participant must contact Calvary Chapel by telephone at 954-556-4563 or via email at AmberB@Calvaryftl.org.

4. If Participant withdraws his or her consent for the electronic Agreement, Calvary Chapel will mail Participant paper copies of the Agreement that Calvary Chapel is required to make after the withdrawal of Participant’s consent; however, the withdrawal of Participant’s consent will not affect the legal validity or enforceability of the electronic Agreement. To the fullest extent allowed by law, Calvary Chapel reserves the right to charge a fee for paper copies of the Agreement in Calvary Chapel’s discretion. Calvary Chapel’s fees for paper copies may change from time to time, and Participant may obtain information about such fees by contacting Calvary Chapel. Calvary Chapel also reserves the right to terminate Participant‘s Agreement in the event that Participant should withdraw his or her consent for the electronic Agreement.

Question Title

* 46. Full Name of Participant:

Question Title

* 47. Parent/Legal Guardian if Participant is under 18 years of age.

Name:

Address:

Phone Number:

Email:

Question Title

* 48. PLEASE CONFIRM YOUR INTENT TO BE BOUND BY THE ABOVE MENTIONED TERMS.
BY SELECTING "I ACCEPT" YOU ARE ENTERING INTO A BINDING CONTRACT/AGREEMENT WITH THE CHURCH.

I Accept

I Decline

Question Title

* 1. How did you hear about this trip?

Question Title

* 2. GENERAL INFORMATION: NAME AS IT APPEARS ON YOUR PASSPORT(Please note: this is the name we will use for an airline ticket, so it must be EXACTLY as it appears on your passport.)

Question Title

* 3. Nickname:

Question Title

* 4. Please check the appropriate box:

Question Title

* 5. Date of Birth:

Question Title

* 6. Age:

Question Title

* 7. Citizen of what country:

Question Title

* 8. PASSPORT INFORMATION:

Question Title

* 9. What is your home church and how long have you attended there?

Question Title

* 10. What ministries are you involved in at your church?

Question Title

* 11. What are your spiritual gifts?

Question Title

* 12. Name a pastor or leader at your church who could give you a reference (Name and Phone Number).

Question Title

* 13. Name two people who know you and your spiritual walk (Name and Phone Number).

Question Title

* 14. Please Describe how and when you came to know the Lord.

Question Title

* 15. Have you been water baptized?

Question Title

* 16. Have you ever served on a mission trip or had a cross-cultural experience?

Question Title

* 17. Please explain why you want to go on this trip.

Question Title

* 18. Please list any relevant medical certifications you have.

Question Title

* 19. Where are you employed and for how long?

Question Title

* 20. Please check all that apply to you.I speak the following language(s):

Question Title

* 21. Please check all that applies to you. I have had the following types of training:

Question Title

* 22. Please check all that applies to you. The mission trip I have attended was with:

Question Title

* 23. Please check all that apply to you. I have been part of the following mission trip(s):

Question Title

* 24. Please check if you are a

Question Title

* 25. What are your personal expectations for this trip? What would make this trip a success for you?

Question Title

* 26. Do you consider yourself:

Question Title

* 27. How does your family feel about your participation on this trip? Was their Response to your decision enthusiastic, skeptical, negative, or supportive?

Question Title

* 28. Have you been involved with any of the following withing the past year?

Question Title

* 29. Have you ever been convicted of a crime?

Question Title

* 30. What are the most significant events that have occurred in your life in the past two years?

Question Title

* 31. What do you see as your strongest character quality and why?

Question Title

* 32. What do you see as your weakest character quality and why?

Question Title

* 33. Do you have any questions or concerns regarding this trip that you would like answered at this time?

Question Title

* 34. Do you have or have you ever had:

Question Title

* 35. Do you have any conditions that might affect your ability to fully function as a team member on this trip?

Question Title

* 36. Do you have any chronic illness or allergies?

Question Title

* 37. Are you presently taking medication prescribed by a doctor?

Question Title

* 38. Have you ever had any psychiatric care or treatment?

Question Title

* 39. Please list any hospitalization History

Question Title

* 40. How would you describe your health and fitness?

* 2. GENERAL INFORMATION:

NAME AS IT APPEARS ON YOUR PASSPORT

(Please note: this is the name we will use for an airline ticket, so it must be EXACTLY as it appears on your passport.)

* 20. Please check all that apply to you.
I speak the following language(s):

* 21. Please check all that applies to you.
I have had the following types of training:

* 22. Please check all that applies to you.
The mission trip I have attended was with:

* 23. Please check all that apply to you.
I have been part of the following mission trip(s):

* 48. PLEASE CONFIRM YOUR INTENT TO BE BOUND BY THE ABOVE MENTIONED TERMS.
BY SELECTING "I ACCEPT" YOU ARE ENTERING INTO A BINDING CONTRACT/AGREEMENT WITH THE CHURCH.