TEAM APPLICATION

Team Destination:

San Pedro La Laguna, Guatemala

Dates of Trip:

PERSONAL INFORMATION

1.

Name:

Address:

City:

State (Province):

Zip:

Phone Number:

(          )

EMAIL:

2.

Place of employment:

Address:

City:

State (Province):

Zip:

Phone Number:

(           )

Job Title:

3.

Date of birth:

Place of birth:

4.

Marital Status:               1Single   1 Married

5.

Passport Number:

6.

In the event of emergency, notify:

Name:

Relationship:

Address:

City:

State (Providence):

Zip Code:

Day phone:

(           )

Evening phone:

(           )

7.

Do you have any medical restrictions or handicaps that we need to make provision for? 1No        1Yes  If yes, explain:

8.

Are you presently taking any medication? 1No  1Yes   If yes, explain:

9.

Health insurance company:

Policy number:

10.

Physician Name:

Phone Number:

SKILLS

11.	Please list any skills you have in languages other than English.
12.	Check any of the skills below that apply to you.  Give further explanation if necessary.
Medical			Construction
1	Doctor		1	Carpentry
1	Nurse		1	Masonry
1	Dentistry		1	Plumbing
1	Nutrition		1	Electrical
1	Other (Name It)		1	Other (Name It)
Computer			Business
1	Programming		1	Accounting
1	Data Entry		1	Management
1	Word Processing		1	Marketing
1	Other (Name It)		1	Other (Name It)
List Type of Computer
Personal Ministry			Other
1	Bible Study Leader		1	Horticulture
1	Evangelism		1	Agriculture
1	Singing (Soloist)		1	Arts/Crafts
1	Musical Instrument		1	Food Service
1	Other (Name It)		1	Other (Name It)
PERSONAL PROFILE
On a separate sheet of paper, write one or two paragraphs on each of the following:
<		A description of your relationship with Jesus Christ.
<		Why you want to be on this mission trip.
<		The realistic roadblocks that might keep you from going on this trip.
<		Any short-term teams you have been on before.

International Travel Release of All Claims

Participants 18 Years of Age or Older

Full Name______________________________________________________________

Trip Location and Date ________________________________________________***

Each year, participants join with Proyecto Fe, Inc. to participate on mission teams. This form is intended to be used by all participants 18 years and older who are participating on such a mission team.  As a condition for participation in the program, you must complete the International Travel Release and Medical Authorization forms. Please carefully read the information below and fill out and sign both forms.

Acknowledgment of Risk and Liability Waiver Agreement

I have executed this release to Proyecto Fe, Inc. I undertake this international travel and participation on this mission team as a voluntary act, knowing that Proyecto Fe, Inc. cannot protect me from risks that may be encountered during this ministry opportunity. I realize there are natural, mechanical, and environmental conditions and hazards that independently or in combination with my activities may cause a serious accident resulting in death, injury, personal property loss, health conditions, or financial expenses as a result of accident, illness, medical care, political upheaval, terrorism, crime, transportation, or other sources of risks.

I hereby state that I understand these inherent risks and dangers involved with participation in this trip and its associated activities, and acknowledge the existence of risks that are not obvious or predictable, and hereby intend this release to extend to injury or loss that results from both obvious or predictable risks, as well as risks that are unpredictable and not obvious.

In consideration of being permitted to participate in this trip by Proyecto Fe, Inc., I and any legal representatives, heirs, and assigns hereby release, waive, and discharge Proyecto Fe, Inc. and its officers, directors, employees, agents, and representatives from any and all liability for any and all loss or damage, and any claim or damages resulting there from, on account of any injury to my person or property, even injury resulting in death, while participating in any activity related to or associated with participation in the aforementioned trip and event.

I agree to indemnify Proyecto Fe, Inc. and its officers, directors, employees, agents, and representatives from any loss, liability, damage, or cost that may be incurred because of my presence or participation in the aforementioned trip, whether caused by negligence of Proyecto Fe, Inc. or otherwise.

This release contains the entire agreement between and among the parties hereto, and the terms of this release are contractual and not a mere recital.

The parties to this release hereby agree that the interpretation and enforceability of this release shall be governed by the laws of the state of the participant.

I expressly agree that this release, waiver, and indemnity agreement is intended to be as broad and inclusive as permitted by applicable laws, and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

I understand that I must purchase international accident and sickness insurance coverage as a precondition to participate in this program.

***           Should I choose to extend my stay in Guatemala beyond that of the mission team or engage in activities or travel outside the itinerary of the mission team, I understand that this is at my own risk and that the foregoing release and indemnification shall apply.

I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW AND UNDERSTAND THE CONTENTS THEREOF. I SIGN THIS RELEASE VOLUNTARILY AS MY OWN FREE ACT WITH FULL KNOWLEDGE OF ITS SIGNIFICANCE, INTENDING TO BE LEGALLY BOUND THEREBY.

__________________________________________________Date _____________________

(Signature of Person 18 Years of Age or Older)

Signature of Parent/Guardian __________________________ Date ____________________

(If participant is still a student in secondary school)

Name Printed ________________________________________________________________

Signature of Parent/Guardian ___________________________ Date ___________________

Name Printed ________________________________________________________________

Home Phone (_____)_________________ Work Phone(_____)________________________

Cell Phone (_____)__________________

MEDICAL AUTHORIZATION FORM

Authorization for Emergency Medical Treatment for Adults

Traveling Internationally

I, ______________________________________, an adult over the age of 18, am voluntarily choosing to participate on the following Proyecto Fe, Inc. sponsored mission team:____________________________________________________________________.

In case of accident, illness, or other emergency, I request that Proyecto Fe, Inc. personnel secure my approval before taking any medical action. If I am incapacitated or otherwise unable to give Proyecto Fe, Inc. personnel my personal approval, I give permission for them to call paramedics or any licensed physician or dentist. I authorize and consent to any X-ray examination; anesthetic; medical, dental, or surgical diagnosis or treatment; and hospital care that, in the best judgment of a licensed physician or dentist, are deemed advisable. I agree to assume the financial responsibility for expenses incurred as a result of those services being provided and for emergency medical transport.

Signature of Adult Program Participant

Signature _____________________________________________ Date ________________

Name Printed _______________________________________________________________

Home Phone (_____)__________________ Work Phone (_____)_______________________

Cell Phone (_____)___________________

Health Insurance Carrier___________________________________________________________________________

Policy # ____________________________________________________________________

Under the Name of ___________________________________________________________________________

Relationship _________________________________________________________________

Name of Family Physician ___________________________________________________________________________

Phone Number with Area Code (_____)_____________________________________________________________________

Allergies (including reactions to medication)

___________________________________________________________________________

___________________________________________________________________________

List of Current Medications

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Are there any physical or medical conditions we should know about that are not already stated on this form?

___________________________________________________________________________

___________________________________________________________________________

If there is a medical or some other type of emergency overseas, whom should we contact on your behalf in the United States?

Name ______________________________________________________________________

Relationship _________________________________________________________________

Phone Number with Area Code (_____)_____________________________________________________________________

PHOTO/VIDEO RELEASE

Adult

I, ___________________________­­­­­_______, hereby grant permission for Proyecto Fe, Inc. to photograph/videotape me, _______________________________________ for possible use on their web page, newsletters, or other published documents where my picture would be helpful in publicizing or promoting the orphanage.

In addition, I grant Proyecto Fe, Inc. and its employees, agents, successors, licensees, and assignees the right and license to use my likeness on photographs or in videos; to crop such photographs at their discretion; to incorporate such photographs or videos in the above projects at their discretion; and to use such photographs or videos or any portion thereof in any manner, including posting on the www.proyectofe.org website as a part of or connected with the above projects, including any promotional materials.

I agree to hold Proyecto Fe, Inc. and its employees, agents, successors, licensees, and assignees harmless against any liability, loss, or damage resulting from the use of my likeness, and I hereby release and discharge any claims whatsoever in connection with such use of my likeness in the above projects.

I understand that my name will not appear in connection with any photographs or videos containing my likeness that may be used in the above projects.

I am signing this release freely and voluntarily, and I am not relying on any inducements, promises, or representations made by Proyecto Fe, Inc. or its subcontractors, employees, or agents.

Consent

Name      _____________________________________________________________________________

Address                 _____________________________________________________________________________

City/State/Mailing Code ________________________________________________________________

Telephone             _____________________________________________________________________

Signature               _____________________________________________________________________

Date        _____________________________________________________________________________