Upcoming Trip Application

Personal Information
Fill out the information of the person applying to go on the mission trip
Name *
Date of Birth *
Date of Birth
Cell Phone *
Cell Phone
Address *
Trip Essentials
(Ex: multilingual, musical, athletics, work with children, experience teaching, etc)
What does this mean to you?
What does this mean to you?
What does this mean to you?
Passport Information
If you do not have a passport, please type n/a in the text fields below
Passport Expiration *
Passport Expiration
If your passport expires in 6 months or less from trip departure date you must get a new passport to be allowed to travel
In Case of Emergency
Please list someone who will not be on the trip with you.
Name *
Phone *
Medical Information
In case of emergency, medical personnel should be aware of the following conditions:
Family Physician Name *
Family Physician Name
Family Physician Phone *
Family Physician Phone
Health Insurance Information
If you do not have health insurance, please type N/A in the fields below
Health Insurance Members' Name *
Health Insurance Members' Name
Terms & Liability
Funds and Preparation *
The following are required - please certify all that you have completed or are committed to complete.
Liability *
I hereby remise, release and forever discharge Harvest Church, its agents, servants, and all other persons, firms and corporations whomsoever of and from any and all actions, claims and demands, whosoever which claimant now has or may hereafter have on account of or arising out of any accident, casualty and/or event which might happen while on a mission trip. I further understand that there is no Worker's Compensation of Accident Insurance furnished by Harvest Church.
Medical Release *
I give Harvest Church consent to act on my behalf in regards to any examinations, injections, anesthesia, medical, dental or surgical diagnosis and treatment; and hospital care and treatment advised and supervised by a physician, surgeon or dentist. To the best of my knowledge, I have listed all of my medical allergies, medications being taken, medical problems and other pertinent information.
Application Terms *
All of the information that I enter here is true and correct to the best of my knowledge. I realize that participating in a Harvest International Mission Trip, I will be reflecting the character of Jesus Christ, the body of believers, and Harvest Church in my conduct. Therefore, I will be fully involved in trip preparation, will complete all assignments for going on the trip, will take full responsibility for raising/paying for 100% of trip expenses (also I realize a refund may not be possible if I cancel my participation), will display a teachable spirit, humble attitude and submit to the leadership of the trip. I am not aware of any medical, spiritual, emotional, or other reason that I should not participate in this mission. I understand and acknowledge that missions participation involves an inherent level of physical and emotional risk. I have read and agree to the release of liability and consent for medical treatment.
Type your full name to sign the form