Journey Application

DISCOVER
OUR PROJECTS
WAYS TO GIVE
WAYS TO GET INVOLVED
HAITI BLOG

DISCOVER
OUR PROJECTS
WAYS TO GIVE
WAYS TO GET INVOLVED
HAITI BLOG

2018 Journey Application: Matty Weston

2018 Journey Application: Mattie Weston

Personal Information

* Indicates required field

Name *

First

Last

First and Last Name as appears on your Passport

Date of Birth *

DD/MM/YYYY

Contact Information:

Mailing Address *

Full Address including Post Code / Zip & Country

Mobile Number *

If you don't have a mobile/cell phone, write 'none'.

Email *

Correspondence will be via email, predominately.

Passport Information:

Full Name as on Passport *

Passport Number: *

Expiration Date: *

Emergency Contact:

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Home Phone: *

Emergency Contact Mobile /Cell / Work Phone: *

Emergency Contact Email: *

Background Information:

Faith: We welcome anyone from any / no faith backgrounds. Please understand and respect that we are an NGO partnering with Christian NGOs (primarily) in the communities we serve. *

Faith - any further brief details: *

Language/s Spoken: *

MEDICAL RELEASE:

Please list any physical or medical limitations: *

Have you had any surgery, major health problems (physical/ mental/ emotional) or been under a physician’s care within the past 3-5 years? *

Yes No

If Yes, give brief details: *

MEDICATIONS:

Please list ALL prescription and non-prescription medications your are currently taking (including dosage): *

Do you have any other allergies (e.g. bee stings, etc.)? *

Yes No

If Yes, give brief details: *

Do you have any food allergies? *

Yes No

If Yes, give brief details: *

Do you have allergies to any medications? *

Yes No

If Yes, give brief details: *

Participation Agreement:

I agree to work with the in-country team as a whole and work cooperatively with each individual on the team. I also agree to respectfully follow directions from LIFLIM leadership. *

I Agree

The information on this form is accurate to the best of my knowledge. *

I agree

Electronic Signature: *

Date Signed: *

Submit